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STATE OFCAUFORNIA r E B 17 1994 ;�� ?o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATIGN 40RIVI A._ HEALTH <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE PERMIT/SERVICES SIL"No" <br /> MARK ONLY NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACIL TY NAMEt5 N E FOP RAT R t <br /> d QU I <br /> ADDRESSD / ^ NEAREST CROSS STRE PARCEL 0(OPfIONAL) <br /> CITY NAME /`/�/ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> to C iT D h CCT CA <br /> TOINDIICCATE CORPORATION Q INDIVIDUAL ®PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' = FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS rel t GAS STATION 2 DISTRIBUTOR '/ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> P� RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYfS: N jME(L ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> &AR r) j') <br /> NIG NAME T) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> 1 � <br /> JaJJJr / <br /> MAILING OR STREET ADDRES ✓ box b Indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Q fs�J a CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ' r STATE ZIP CODE PHONE#WITH AREA CODE <br /> o a 6 ? 467 o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E OF OWNE d CARE OF ADDRESS INFORMATION <br /> on yl <br /> MAILING OR STRIEET ADDRESS ✓ box a indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> l CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COPE PHONE s WITH AREA CODE <br /> _ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 0 1 SELF-INSURED 2 GUARANTEE = J INSURANCE ( 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER SM Tr F u 4 D <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. II.IK?l 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&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY C. )jji. 5 <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL C US TRACT# -OPTIO 3UPVISOR TRICT COQE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIEb*AVALLUAPRf0RE PERMIT APPLICATION- FORM 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 REGULATI[M <br /> FORM A(3193) FOR0069A-R7 <br />