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STATE OF CALIFORNIA o� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [::] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FORA4R FAi <br /> LITY NAME NAME OF OP ATOR <br /> c/ '!Y- / T2 14 OA PAS <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAM STATE ZIP CO� SITE PHONE#WITH <br /> Lo�r AR A CODE <br /> ✓ f30x ��ORPORATION i�INDIVIDUAL i�PARTNERSHIP LOCAL-AGENCY <br /> TOINOICATE DISTRICTS' 0 COUNTY-AGENCY STATE-AGENCY' (] FEDERAL-AGENCY' <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 i GASSTATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 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) PITH AREA CO E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A SW—V, ZZ %� <br /> NIGHTI: NAME(LA T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 110 1k4., - 3300 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> v4- <br /> MAILING OR STREET ADDRESS ✓box IDindicate <br /> = INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> /00 Z> Q Qd CORPORATION = PARTNERSHIP = COUNTY-AGENCY E:j FEDERAL-AGENCY <br /> f CITY NAME V —1 <br /> O STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME Of OWNER I CARE OF ADDRESS INFORMATION <br /> - <br /> MAIQLjNG OR STREET ADDRESS ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY <br /> /- 0- Ap.,volA7Q 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#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 4 - D 114-11 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate E371,,SELF-INSURED (]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT 6 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. 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&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Z -si <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> c <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE 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 REGULATKW <br /> FORMA(3/93) F0R000�.R7 <br /> 0 0 <br />