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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `' '•��"'' <br /> MARK ONLY t NEW PERMIT F__j 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED!SITE <br /> ONE ITEM (-__j 2 INTERIM PERMIT F-1 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> hFA OR FACIL 1r �.ME NAME OF OPERATOR <br /> pa <br /> ADDRESS /� NEAREST CROSS STREET <br /> PAACELe(OPTgNAu <br /> CITYNA r — -- STATE ZIP f o SITE PHONE a WITH AREA CODE <br /> ( CA <br /> X <br /> 10 INDICATE CORPORATION kI INDIVIDUAL '�PARTNERSHIP LOCAL-AGENCY <br /> COUNTY-AGENCY' O STATE-AGENCY' a FEDERAL <br /> DCSTRI'II 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 - -1 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 10 OF�AT SITE E.P.A. I.D.4(oprwnal) <br /> - <br /> RESERVATION <br /> 3 FARM4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS�ME T.FIRST) � PHONE*WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo=b indicate 0 INDIVIDUAL O LOCAL-AGENCY ,�STATE AGENCY <br /> (�CORPORATION O PARTNERSHIP O COUNTY-AGENCYL�FEDERAL-AGENCY <br /> t - -- __._ ------- ._ -- ----- <br /> i C,TY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME PF OWNER CARE OF ADDRESS INFORMATION <br /> - <br /> MAILING OgyS,Tqt`,q}7'T SS t ✓ boKbindicate INDIVIDUAL (� LOCALAGENCY STATE-AGENCY <br /> ",/ Vl-P'_ {"--' CORPORATION PARTNERSHIP 0 COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME ST T 0-[`HONE 0 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ i 4 I4- <br />" V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F <br /> iD i dk,ue 1 SELF INSURED 2 GUARANTEE �_' 3INSURANCE [ ]4 SURETY BOND <br /> LJ S LETTER OF CREDIT 15016 EXEMPTION U 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: L C—II I.jam,' 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 6 SIGNED) OWNER'S TITLE DATE MONTwDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION A FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACT I -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 IWORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKM <br /> FORMA(3/g3) _ n �� ` �FOROO13AfiT <br />