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STATE OF CALIFORNIA ,� %� <br /> STATE WATER RESOURCES CONTROL BOARD '„�� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE °���.a.�'- <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT lm�, TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO LI NAME EMTOR <br /> NAME OF YU & A 'o N <br /> AOD 33 L NEAREST CROSS STREET V PPARrEU(OPrIONAU <br /> CITY NAM ( U 3T CA zr,5aD Slg�QPHONE#WITH AREA COOS <br /> T N Box I �RPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY- <br /> DISTRICTS' <br /> N saner cl UST Is a public agency,con ipsas the lollowing:name of Supervisor of oNbbn,sectbn,m office which operates the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.A(cphorell <br /> 3 FARM 4 PROCESSOR 6 OTHER RESERVATION <br /> ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHOaL a WIT ARE CODE DAYS: NAME(LAS ,FIRST) PHON s WITH AREA CODE <br /> O�L1VK44 3-7 <br /> NIGHTS: NAME(LAS T.FIRST) PHONE0WITH AREA CODE NIGHTS: NAME VILST,FIRST) PHONE AWITH AREA CODE <br /> R. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bMbh6kaq ED INDIVIDUAL O LOCAL-AGENCY 0 STATE-AoENCY <br /> E3 CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERLL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Imtbindcami INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP O 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(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bMditte ED I SELF-INSURED D 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT 0 6 EXEMPTION Ij 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or lI is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ it.Q 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 a SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> am <br /> LOCATION -OPTIONAL CENSUS TR�TA OP SUPVISOR-DIBTR`TOCOE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORYA ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO11 iL <br /> FORMA(393) <br /> ( y "—b <br /> '/-T Fdi005NID <br />