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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD yrs =� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ; - , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE 1/ e <br /> MARK ONLY I NEW PERMIT a 3 RENEWAL PERMIT5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q A AMENDED PERMIT & TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / NAME OF OPEpATOR <br /> ADOR ,S/ NEAR S.T ^Q STREET PARCEL I(OPTIONAL) <br /> 3 (T( S Iry/I1 G,1 ie�I�pC e� t� <br /> DnYNAME�/- STATE <br /> REA CODE <br /> CA Z/ JlH3 L-CODE SITE 09 <br /> E#WITH07 `0r4 <br /> ✓BOX ' / 0/QCORPORATION ZNDMWAL = PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> ' A pmwrd UST i a WCk a{renry,mrtpkle me IOIbrmQ.name d supervisor d fnaion,sepbn wdfiu.midi opeNln Ne UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR 0 RESEIRVAT10N /�T�ANKS AT SITE E P.A I.D./(op�ional) <br /> Q 3 FARM O a PROCESSOR 5 OTHER ORTRUSTLANDS Phe— 0 0A 22ta 9 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS NAME(LAST,FIR T) I PHONE I WITH ARBA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> vm 7,107 <br /> NIGHTS: NAME(UST,FIRST) I.W PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE I WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L <br /> MAILING OR STREET ADDRESS• e `� ) ✓ LOik^&e- MDMWAI EDLOCAL-AGENCYSTATE-AGENCY <br /> 2 S �`��_ Ver (]CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME �G `I/!/F/STATE-A 21P LADE ` PHONE I ITH AgEA C DE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) {/ V 4��✓ � /Y] <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 5mbb5ioM INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION (]PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 /V I`+ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE�OMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Dpab ibirau I SW.INSURED 2 GUARANTEE O 3 INSURANCE []A SURETYBOND O 5 LETTEROFCREDIT O&EXEMPTION CD T STATE FUND <br /> O&STATE FUND I CHIEF FINANCIAL OFFICER LETTER =0 STATE FUND&CERTIFICATE OF DEPOSIT OIII LOCAL GOVT.MECHANISM O P90THER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 5z <br /> I RI.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNONIEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PAIN- D&SIGNA E) I TANK OWNER'S TITLE W <br /> DATE MONTDAYNEAR <br /> LOCAL AGENCY USE ONLY C 200 L (� . <br /> COUNTY X JURISDICTION I FACILITY I <br /> LOCATION CODE •OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR•DISTRICT CODE -OPTIONAL <br /> o I a3 , 00 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR? H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' n STORAGE TANK REGULATIONS 9 �p ///� <br /> FORM A(&-95) �� q—I V / I ,1(_,//es <br />