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Mf <br /> !xe � <br /> 5� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE c- - <br /> T PERMANENTLY CLOSED- <br /> O 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION - <br /> MARK ONLY 1 NEW PERMIT S TEMPORARY SITE CLOSURE <br /> ONE REM <br /> 2 INTERIM PERMIT Q 4 AMENDED PERMIT <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> MEOFOPERATOR <br /> DBA ORFACILITY NAME pMCELb(OPTgNAU <br /> I <br /> I NEAREST CROSS STRE <br /> ADDRESS j- <br /> r STATE ZIP ITEPHONEI WITH AREA CODE <br /> CITY N ME�� CA <br /> I <br /> -1C CORPORATION 1� <br /> BOz INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' O <br /> gCATE T]�I CORPFFDEML-AGENCY' <br /> TOIN0 DISTRICTS' <br /> 0•X owner of UST la a pu c egenm corrglete the fallowing:name of Supervisor of division,saclbn,w office whkh operates the UST <br /> ✓ IF INDIAN A OF TANKS T SITE E.P.A. I.D.+e(optimal) <br /> TYPEOFBUSINESS 1 OASSTATION 2 DISTRIBUIU" 0 RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS , <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D//��YS: NAME(LAST. _ P ONE aY�ITH AREA CODE PAYS: NAME(LAST,FIRST) PHONEa WITH AREA CODE <br /> NIGHTS: NAME JMASST)ST) HONE a H AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Io WioN INDIVIDUAL 0LOCAL-AGENCY OSTATFA NcY <br /> CORPORATION = PARTNERSHIP O COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEx WITH AgEA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0W to INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> CITY NAME <br /> CORPORATION PARTNERSHIP EDCOUNTY-AGENCY (] FEDERAL AGENCY <br /> STATE ZIP CODE PHONE a W ITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322-9669 if questions arise. <br /> TY(TK) HQ4 4- - n <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindeaia [_1 1 SELF-INSURED Q 2 GUARANTEE El 3 INSURANCE <br /> 5 LETTER OF CREDIT 6ExEMPnON I� dSURETY BOND <br /> k9.90 OTHER ' <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY _ , r <br /> COUNTY x JURISDICTION# FACILITY• <br /> C <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE I FORMATION ONLY. <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKIHS <br /> low <br /> FoRomaA 97 <br />