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STATE OF CALIFORNIA `�~ ""• °: <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r�L,Fp'•N'� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLI SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME i • W 's'a:j NA E OF OPER TDR <br /> 1405 LIFC)RNIA STREP a� <br /> ADDRESS ESCALON;CALFI0} VIA 95320 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STAT CODE SITE PHONE#WITH AREA CODE <br /> ✓ BOX CA ^ I <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY [] STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P-A. I.D.#(optional) <br /> RESERVATION 3 <br /> 3 FARM � 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-oplIonal <br /> M ME(LAST,FIRST) PHOT W�H EA CPE DAYS: NAME(LAST,FIRST) <br /> oy- <br /> NIG S: NAME(LAST, RST) PHONE#WITH AREA CO1DE NIGHTS: NAME(LAST,FIRST) <br /> I WITH AREA QODr <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR S R ETADDR SS ✓ bwo indicate INDIVIDUAL Cj LOCAL-AGENCY STATE-AGENCY <br /> f0 CORPORATION 0 PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY E STAT ZIP COPHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA F OWIR CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS j ✓ box tolndkate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE <br /> 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 FXEMPT99 OTHER <br /> ION O <br /> 0 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the ed. <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT4r -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) 00.0033 <br /> 1 <br />