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• STATE OF CALIFORNIA • a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F7 t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FACILITY AME �/ NAME qF OPERATOR 4� /A�• _ <br /> AODR n LE/SSTTTCR! TREET %%'/i/�•5��,'// PMCELeIOPfgNAp <br /> Inc <br /> C7N STATE Of ZIP DE / ON WLTVAREAMI <br /> CA C/^/ <br /> TOINDICATE CORPORATION O INDIVIDUAL PARTNERSHIP DOTAL-AT9ENCY O COUNTY-AGENCY' O STATE-AGENCY' D FEDERAL#GENCY' <br /> •N tamer d UST Is a public agency.complete the following:name of Supervkor of dNkbn,eecllun,m office Which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR RESERVATDION e�TANI{S AT SITE E.P,A. I.D.a(apNonaq <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS / <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 a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkale ED INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 w Mixes INDIVIDUAL LOCAL-AGENCY D STATE AGENCY <br /> CORPORATION O PARTNERSHIP D COUNTY AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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:R]-10 12�tfl 9�74� <br /> V <br /> 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkate 1 SELF-INSURED2 ARANTEE 3 INSURANCE (]4 SURETY BOND <br /> D 5 LETTER OF CREW EXEMPTION 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.❑ IL❑ 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(PR INTED B SIGNED) OWNER'S TITLE DATE MONTWUAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CON a JURISDICTION I � FACILITVa <br /> LOCATION CODE TIONAL CENSUS TRA91,1TI [J� SUPVISORn IS RI T j TIONAL <br /> T <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION•VORW B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) i�1 FOR9009A8T <br />