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' f�yWe f <br /> STATEOFCAUFORNA ^� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> G e UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A W tl <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> /�^ ��tinOa Yin <br /> MARK ONLY f NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION [-] 7 PERMANENTLY C SITE <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACT TY NAME NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#IOPTIONAU <br /> CITY NAME w i 4/ <br /> ��- STATE ZIP CODE PH�{+Ey WITH AREA CODE <br /> .1 Box .�q CA qs2 J 36 F- r2 <br /> TOINDICATE O CORPORATION rJ NDIVIDUAL [:::)PARTNERSHIP EDLOCAL-AGENCYEDCOUNrRISTRICTS' CY <br /> AGEN - STATE-AGENCY' <br /> H owner Of UST to a Public agency,wopm <br /> leN,the lollowing:nae Of SOPervbor of dWiOn,section, aperales the UST <br /> or Office which FEDEMIAGENCV• <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(gorianalJ <br /> 0 RESERVATION -It <br /> 3 FARM q PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NA E(LAST FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,F_L PHONE M WITH AREA CODE <br /> sG� I F l� Z 365-/24 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G El. <br /> MAILING OR STREET DRESS r box bindicab <br /> / O INDIVIDUAL LOCAL AGENCV = STATE AGENCY <br /> CITY NAME L L-1 CORPoMTI 0 PARTNERSHIP 0 COUNTY-AGENCY E�:j FEDERAL-AGENCY <br /> v^ STATE Z COD��� PHONE WITH AREA CODE <br /> o� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME Of OWNER <br /> �. i-- � �-- CARE OF ADDRESS INFORMATION <br /> r c <br /> MAILIN OR STREET ADDRESS ✓ box biMkyo <br /> 0 INDIVIDUAL [:J LOCAL AGENCY Q STATE AGENCY <br /> CITY NAME CORPORATION Q PARTNERSHIP E=I COUNTYAGENCY = FEDERALAGENCY <br /> f ti STATS ZIP CODE P ONE p ITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ F4-[4--]- •Call 6)322-9669 if questions arise. <br /> (91 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa Ioal ata E-1 I SELF-INSURED 0 2 GUARANTEE E--1 3 INSURANCE <br /> C-1 5 LETTER OF CREDIT O 6 EXEMPTION (] %OTHER O A SURETY BOND <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: <br /> L[7] II. III. <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 8 SIGNED) <br /> DATE MONTWDAYrYEAR <br /> LOCAL AGENCY USE ONLY 3. OWNER'S TITLE a o2 p IQ (� <br /> COUNTY# JURISDICTION# CIL <br /> e A <br /> LOCATK)N CODS -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOFI- <br /> DLSTRN;TCODE .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(393) OWNER MUST FILE THIS FORM WITH E LOCAL AGENCY IMpLEIENTING THE UNDERGROUND AGE TANK REGULATIONS <br /> FMOOM417 <br />