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STATEOFCALIFORWA r' g <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> / COMPLETE THIS FORM FOR EACH F LRYISITE <br /> MARK ONLY F-1 f NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMAN5NTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) <br /> DBA OB.FACILITYN ^ - ^ NAME F RATO <br /> ADDR'EESSSSSS Jl /vl NEAREST CR Be STflEET PARCEL#(OPTIONAL) <br /> CITY N ME /) STA ZIP CODE SITE PHONE k WITH AREA CODE <br /> CA <br /> ✓ BOx0 CORPORATION D Imam ED PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' f�STATE-AGENCY' O FEDERAL-AGENCY' <br /> TOINDICATE DISTRICTS, <br /> •ff owner d UST is a public agency,complete the loIhANng:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / 0 R SERVATION kOF TANKS AT SITE E.P.A. I.D.k(oprknag <br /> Q 3 FARM 4 PROCESSOR e5 OTHER OR TRUST LANDS L/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS NAME PST,FIRST) " f PHONE k WITH AREA COD ENNA <br /> (LAST]FSIREST) E <br /> PHONE k WITH AREA CODE <br /> A /NG_te./LJ O <br /> NIGHTS: NAME(L T,FIRST) PH WITH AREA CODE ME(IAPH ONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMk -'_ _ T'J CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 10 Mom � IN <br /> O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNfY-AGENCY FEDEIULAGENCV <br /> CITY NA E STA 21P CADE� PHONE k WITH AZEA COD 2 8 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) S '2S/J J <br /> NAME OF OWNER p � CARE OF ADDRESS INFORMATION <br /> 5- 1 <br /> MAILING OR STREET ADDRESS(.1 ✓husbbd¢ale O INDIVIDUAL = LOCAL-AGENCY E-D STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP = COUNTY-AGENCY [__1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- -�ID <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bot bindkate 1SELF-INSURED Lj 2 GUARANTEE 3 INSURANCE l�4 SURETY BOND <br /> D 5 LETTEROFCREDIT D 6 ExEMPTION Ss OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication and billing will be sent to the tank owner unless box I or II is ch <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.El 11. III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAM E(PRINTED 6 SIGNED) OWNERSTTTLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY III <br /> am <br /> LOCATION CODE -OPTIONAL CEN SUS TRACT# -OPTIONAL 9UPVISOfl-DISTRICT CODE -OPTADAW. I� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONO. <br /> OWNER MUST FILE THIS FqRM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FanGmxa2 <br /> FORM A(393) * *- f /` (, ISw1b MTS [[[ <br />