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J STATE OF CALIFORNIA M1'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> t A UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> COMPLETE THIS FORM FOR EACH FAClUTYISITE `'�PU1,M•' <br /> MARK ONLY F-1 f NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CL <br /> ONE REM 0 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CI <br /> Yv <br /> N E NAME OF OPERATOR <br /> �i n� Cas w v <br /> ADDRESS f NEAREST CROSS STREET PARCEL A(ORIONAU <br /> CITY NAME STATE 21P QE_ 917E PHONE i WITH AREA CODE <br /> CA <br /> TOIN'box COR TION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY <br /> O HICTSENCY OOUNTY-AGENCY' O STATE-AGENCY' O FEDERAL AGENCY' <br /> N owner of UST Is a public agency.ccnplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS f GAS STATION Q 2 DISTRIBUTOR R SEIF INDIAN I I <br /> RVATTION i OF TANKS AT SITE E.P.A. I.D.#(gNlw7eg <br /> 0 3 FARM a PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME ST,FIRST( PHONE WITH REA CODE DA S: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �b — <br /> NIGHTS: NAME(LAST,FIRST) WIT EA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbindbaN 0INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate D INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE i 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- -16)L31511 NLI <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bintlieah, =1 SELF-INSURED 2 GUARANTEE E-1 31NSURARCE I�A SURETY BOND <br /> O 5 LETTEROFCREIXT O h EXEMPTION 07XER <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.❑ III.0 <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&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY q In__4 <br /> COUNTY x JURISDCTION a FACILITY f <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL 9UPVISOR-OL4TRK:T CGDE-OPTpAW- <br /> y <br /> fj-D ✓ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE)T(HIS FORMWITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> RM A(/W N I'S `-' '-R7D <br />