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It", // <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />60UR e <br />np <br />to AE m <br />0 <br />• C�(IfpN <br />(j COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT*116 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBAQR FACILITY NAME <br />CARE OF ADDRESS INFORMATIO <br />S <br />NAME OF OPERATOR <br />MAI R 4 <br />.�j�J <br />= LOCAL -AGENCY <br />c -4' <br />CITY NAME <br />Ger <br />S <br />ADDRESS <br />STAT <br />ZIP CODE <br />NE)A�R�STCROPSSTREET <br />AREA CODE <br />PARCEL#(OPTIONAL) <br />x <br />$ <br />1/V <br />CITY NAME <br />STATE <br />"zipZS4 <br />SITE PHONE WITH AREA CODE <br />CA <br />d f ? " ,A <br />TO DIC TECORPORATION <br />E�D INDIVIDUAL 0 PARTNERSHIP <br />0 LOCAL -AGENCY Q COUNTY -AGENCY <br />STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN <br />RESERVATION <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM <br />0 4 PROCESSOR 0 <br />5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NA E (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST)! 1 ? — , <br />NIGHTS: NAM (LAST, FIRST) PHONE ITH AREA CODE NIGHTS: A (LAST, FIRST)PHONE # WITH AREA CODE <br />1 <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME ; / <br />CARE OF ADDRESS INFORMATIO <br />S <br />MAI R 4 <br />✓ box to indicate INDIVIDUAL <br />= LOCAL -AGENCY <br />Q STATE -AGENCY <br />CITY NAME <br />CORPORATION PARTNERSHIP COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAM <br />STAT <br />ZIP CODE <br />PHONE # WITq <br />AREA CODE <br />III. TANK OWNER INFORMAL ION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />S <br />MAILING OR STREET ADDRESS "' <br />✓ box to indicate INDIVIDUAL Q LOCAL -AGENCY STATE -AGENCY <br />= CORPORATION PARTNERSHIP COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 -10 A 7 -71616 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to Indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br />E: 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. D I1X III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # ( t { JURISDICTION # FACILITY # 0()/S70 <br />';�o r o a <br />LOCATION CODE - OPTIONAL CENSUS TRACT_# - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />�]^3 t <br />THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORM <br />FORM A (5-91) _®r L 7�j OR 3A-5 <br />Y3 <br />