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STATE OF CALIFORNIA " <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD 3" <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR AGILITY NAME a4w � Z/b NAMM FIkeOPERATORRICO :!VDau <br /> ADD SI n A NEARE CROSS STR Er ARCELN(OPfONAU <br /> CITY NA K/V STATE L ZIP D27 <br /> ��0 SITE PNO #WITH'RO� <br /> p Ca <br /> EA <br /> v BOX <br /> TOINDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP E=I LOCAL-AG <br /> $ENCY 0 COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRITYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR = <br /> RE/ IF INDDIAN #OF TANKS AT SITE E.F A. I.D.#(optimal) <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRS PHONE WITH AREA r!OnE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �1 CARE OF ADDRESS INFORMATION <br /> rc r s 1/Nin <br /> MAIL I OR TREET DRESS / ✓ bo>Ibhtl¢me O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> _ CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITU N MESTA'j( �. ZIP pE DZ �/ PHONE��ARE -Z <br /> r e5ia � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREETADDRESS ✓ babhWbtl4 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O 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)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - Q <br /> V. PETROLEUM UST FINANCI�L RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hm blrANNe I SELF-INSURED D 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> E� <br /> 5 LETTEROFCREDIT O 6 EXEMPTION Q W 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 ecked. <br /> CHECKONE SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.EVIII.❑ <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 TIRE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY `` nnn yyy <br /> COUNTY# JURISDICTION# FACILITY# /� 92- <br /> LOCATION CODE -OPTIONAL CENS2jkCT�� - <br /> -OPTIONAL SUPVISO 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 INFORMATION ONLY. <br /> FORM A(5-91) FOROM3A3 <br />