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STATEOFCAUFDRNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 °' <br /> .1 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> �• COMPLETE THIS FORM FOR EACH <br /> MARK ONLY F__j 1 NEW PERMIT I] 3 RENEWAL PERMIT 5 CHAN& OF NFORMATION 7 PERMANENTLY C <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT TTEMPORARY <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) 3 I V <br /> AORFCI / ^„ d'4'�d� NAME OF OPERATOR 114. a(r <br /> ADDRESS ^fel/�'A�r( c3�1/ ! ka <br /> NEAREST CROSS STREET PARCEL#(OPFKINAU <br /> CITY NAME STATESITE PHONE#WITH AREA CODE <br /> CA #1 - 832— <br /> TOINDICRTE O COR RATX)N INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY =COUNTY-AGENCY' STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS, <br /> •Namer of UST Is a public agency.eonplete Uw IoAowne:narre o/Supervisor M tlNlebn.aeclbn, <br /> which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.0(aptione8 <br /> ESERVATION <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER ORTRUSTLANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME T.FIRS PHONE WITRE CODE DA S: NAME(LAS Sof PHONE#WITH AREA GODS <br /> :, fr(�a 1 Ira.. 20?� $32-$Z�3 <br /> NIGHTS: NAME(LAST.FIRST) ONE#WIT AREA 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 ✓ box binkab INDIVIDUAL ED LOCAL-AGENCY O STATE-AGENCY <br /> 2q g U t d5 CT�o�� CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEOERALAGENCY <br /> CITY NAME STATE ZI�CODE PNE#WITH AREA CODE_ <br /> S 71J10- <br /> III. TANKOWN6 INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbaw INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL#GENCY <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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicato O 1 SELF INSURED [71 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> E]5 LEREq OF CgEDIT 6 EXEMPTION 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNEWS NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY a <br /> COUNTY# JURISDICTION# FACILITY# �(v3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> _-3 .,� <br /> THIS FORM MUST SE ACCOMPANIED BY AT LEAST(I)OR MORE PERMITAPPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SIZE INFORMATION ' <br /> RMA(393) OWNER MUSTFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING.THE UNDERGROUND STORAGE TANK REGULATIONS <br />