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STATE OF CALIFORNIA <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 F__j 1 NEW PERMIT F__j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CL S <br /> ONE ITEM Q 2 INTERIM PERMIT F7 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME` // NAME OF OPERATOR A <br /> If-f <br /> ADDRESS NEAREST CROSS STREE PARCEL#(OPTIONAL) <br /> /--/'7-74. w <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA E <br /> CA <br /> I/ BOX ,,,���....�,,//�� LOCAL-AGENCY <br /> TOINgCATE O CORPORATIONDIVIDUAL PARTNERSHIP COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <br /> `It owner of UST Is a public agency,complete th following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 R SER ATINDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> ON <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AY TT - <br /> NIGHTS: NAME(LAST,FIRST) P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A '- / -7 <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ..��AAX­r I AYds <br /> MAILING OR STREET ADDRESS ✓box b Indicate INDIVIDUAL (] LOCAL-AGENCY EDSTATE•AGENCY <br /> 7p S-1 . (J ��� (]CORPORATION PARTNERSHIP COUNTY-AGENCY =) FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> f 4 Y GS <br /> MAILING OR STREET ADDRESS ✓ box to indicate NDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> Q� �jT- `S(.-� � LA — <br /> =CORPORATION = PARTNERSHIP 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) HQ F4_4-1-1 I I I _I I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bIndicate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT Q 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.W II.0 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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> i <br /> LOCATION CODE -OPTIONAL ___]CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77014AL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN10MAT&6NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINS <br /> FORM A(3193) 0 <br /> 0 <br /> FOR6633A.11117 <br />