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`! r <br /> STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD W 4ea <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , ;s <br /> COMPLETE THIS FORM FOR EACH FA /SITE �4kipoR01' <br /> MARK ONLY F__] t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME NAME OF OPERATOR <br /> .G <br /> AD E S NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2 <br /> CITY NAME STATE ZIP CODE SI PHO E#WITH AREA CODE <br /> CA !� pCv (2 0 - /C) <br /> TO DBI ATE (]CORPORATION =INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' (]FEDERAL-AGENCY <br /> DISTRICTS' <br /> h owner of UST is a public agencpaornplets,the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS i2rl GAS STATION = 2 DISTRIBUTOR 0 RESER INDIAN #OF TANKS AT SIE E.P.A <br /> T . 1.D.#(optional) <br /> 0 3 FARM = 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPER - MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> leg <br /> AILING OR STREET ADDRESS p ✓ box b indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> X $G CORPORATION = PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> NAME _ STATE ZIPDE PH E#WITH AREA CODE <br /> 3-1 <br /> III. TANK OWNER INFORMATION-(MUS BE COMPLETE <br /> NAME OF OWNER n CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate EE INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ff:1 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 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) HID M44- - Q Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b indicate Q 1 SELF-INSURED [__1 2 GUARANTEE 0 3 INSURANCE (]4 SURETY BOND <br /> O 5 LETTER OF CREDIT =6 EXEMPTION 0 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: <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#OO 3735 <br /> �A] N20 :/]am <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 tATE I MATION ONLY. <br /> FORM A(3/93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATOG FOR0031"7 <br />