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0 0 <br /> tBOUR <br /> STATE OF CALIFORNIA .? <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD w��, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A -e <br /> +x.• ti <br /> 4HN�� <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Lv5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE p/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRAOR FACILITY NAME NAME OFO EflATOR f�� <br /> ADORS (� � [ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CI N M STATE ZIP C.qO��/ SITE PHONEX WITH AREA CODE <br /> T,/ BOX <br /> XTE O CORPORATION D INDIVIDUAL l�PARTNERSHIP 0 DS fl-AGENCY D COUNTY-AGENCY STATE AGENCY FEDERAL-AGENCY <br /> ICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION *OF TANKS AT SITE E.P.A. I.D.M(optional) <br /> / IF INDIAN <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0Irdbale INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP Q COUIfYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Wicale M INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP D COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F44_ - O Z (0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biiMicale = 1 SELF-INSURED k GUABAMEE I= 3 INSURANCE 0 4 SURETYBOND <br /> D 5 LEn EROFCREDIT 6 EXEMPTION I= 99 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.❑ I.❑ Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# FACILITY M <br /> " lnT All I / I <br /> 25 , <br /> LOCATION CODE -OPTIONAL CENSUS TRRRACT oOPT10NAL SUPVISOR-DISTRIC 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 INFORMATION ONLY. <br /> FORM A(5-9d) � � / <br /> FOR <br />