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! C <br /> STATE OF CALIFORNIA .t <br /> STATE WATER RESOURCES CONTROL BOARD W 4a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os <br /> COMPLETE THIS FORM FOR!2 FACILITY/SITE 'Lwo.", <br /> MARK ONLY a 1 NEW PERMIT 0 3 RENEWAL PERMIT FVj 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR F,A,CILITY AME F,. NAME OF OPERATOR <br /> rDarnell EppW I March Lane 78 <br /> ADD;a�S1 W. March Lane NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> u i-Warch Lane <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ` <br /> ik1RR7N/11 CA 1 95207 2091!473-7337 <br /> ✓ Box <br /> TO INDICATE [:XCORPORATION = INDIVIDUAL =PARTNERSHIP 0 LOCAL-AG <br /> SENCY COUNTY-AGENCY' Q STATE-AGENCY' (� FEDERAL-AGENCYDISTRI ' <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 1 GAS STATION 2 DISTRIBUTOR RESERVATIONIF INDAN is OF TANKS AT SITE E.P.A. 1.D.*(optima) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 CAD982057432 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> 't% S FIR�TMa�Lane 76 PHONE#LtJRl/iF l33/ DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> UI%W&* T%rch Lane 76 PHONE#L___lhHl/AR l3C-/D33/ NIGHTS:NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Union Oil Company Of CA,dba Uncal CARE OF ADDRESS INFORMATION <br /> MAILINrOBSTBEET �T�56S ✓ boxwindieste INDIVIDUAL 0 LOCAL-AGENCY C1 STATE-AGENCY <br /> Box�1`�;jj ff CORPORATION a PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N9 ;nta Ana STATE ZIP CODE 92799-5376 PH�p ,�1(VI�pE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAW ' CARE OF <br /> unIon&COmpany Of Calftmta, dba Uncal EvironeaI _ -1arim <br /> MAILING OR STREET ADDRESS ✓box binds (] INDIVIDUAL (]LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 25576 (CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$WITH AREA CODE <br /> Santa Ana CA 92799-2358 (714)428-MM <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- -1qI 1= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box o indicate 1 SELF-INSURED a 2 GUARANTEE (] 3 INSURANCE Q 4 SURETY BOND <br /> C)5 LETTER OF CREDIT 6 EXEMPTION (]99 OTHER <br /> V1. 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 W41CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 it.a 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 MONTW YNEAR <br /> ���1�'�' S � PLI�f"J✓�L Co�YN� � y <br /> LOCAL AGENCY USE ONLY I� <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -!`PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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 INFOR ON ONLY. <br /> OWNER MUST FILE THIS FOW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRWORAGE TANK REGULATIONS <br /> FORM A(3W) FOR=3"7 <br />