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U. <br /> e <br /> STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY ED.SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA Oct FACILITY NAME NAME OF OPE TOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ,A]. Lam, 19114CV40 O2_.'7— — <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITJAAREA CODE <br /> G %oo CA 3Z�/ <br /> T IO NDICCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q 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 W1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> Q Q OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM (LAST.FIRST) PHONE#WITH AREA CODE tN <br /> AME(LAST,FIRST) PHONE WITH AREA CODE <br /> ,q/ 9 —DSZS e k, <br /> NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME.�� CARE OF ADDRESS INFORMATION <br /> MAILING OR STRE.Er ADDRES1 box to indicate KINDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Z?j 6 /OI 1i0.� Q CORPORATION Q15ARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> i CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> z P,q- , S 333��gn <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN R C CARE OF ADDRESS INFORMATION <br /> !3K- <br /> MAILING O STIR ET ADDR SS ✓ box to indicate DIVIDUAL QLOCAL-AGENCY Q STATE-AGENCY <br /> 2 6 Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME� STATE_ ZIP�� PHONE yWITH EA CODE�D <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER- all(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4- - D "� / / <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCESQ 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER 5A-47126 61019G'J^�' 1 <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: 1.❑ 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) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Z ► 3 <br /> LOCATION CODE -OPTIONAL 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 IN06RMAtiON 6NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � � FOti0033A-R7 <br />