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STATE OF CALIFORNIA <br /> ���� � ♦46VUA ( <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETMISFORM FOR EACH F ILRY/SITE <br /> MARK ONLY / I NEW PERMIT 3 RENEWAL PERMI Vlf <br /> CHANGE OF INFORMATION 7 PERMANENTLY LOSED.Si./�Y J <br /> ONE ITEM i 2 INTERIM PERMIT Q A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �� 66��JJv�� <br /> I. FACILI (SITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FA ILITY NAM / • v V� NAME OF OPERATOR <br /> ADORES �76/`�' �� NEAREST CROSS STREET PARCELA(OPTONAL) <br /> CITU NAME � STATE ZIP���.// SITE PHONN=N W�AREA=O�E�. <br /> ✓ sox <br /> TO INDICATE D COR ON 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY ICTS (] COUNTY-AGENCY D STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS 7 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN NOF TANKS AT SITE E.P.A. 1.D.N(optiOnal) <br /> 0 RESERVATION <br /> Q 3 FARM Q 4 P R 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH NE X WITH AREA COOE DAYS: NAME(LAST,FIRST) <br /> PHONE WITH ARPA rOOE <br /> NIGHTS: NAME(LAST. ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA COD' <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabintlk Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbilbbab Q INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP [I] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 Q /pj <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa 0inEba1e = I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE O d SURETYBONO <br /> l=5 LETrEROFCRED-r Q 6 EXEMPTION O 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.0 III. <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 MONTWDAYNEAR <br /> -2-7-7 f9 74- <br /> LOCAL <br /> LOCAL AGENCY USE ONLY W <br /> COC A ���,/v JURISDICTION p FACILITY N . <br /> l�U `I � fiT.,�rrTiT^rl `IZ/1�71 <br /> LOCATION CODE QPTONAL ICENSUS TR CYN -OP77ONAL SUPVISOR-DISTflICT CGDE -OPTIONAL <br /> THIS FORM MUST BE BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- F RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FORW77A-5 <br /> L <br />