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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �,�,•eM1,,,.' <br /> 1 NEW PERMIT IJAL 5 CHANGE OF INFORMATION _I`_ 7 PERMANENTLY CL <br /> MARK ONLY 3 RENEWAL PERMIT �\ <br /> ONE REM 2 INTERIM PERMIT O a AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFIVCIL�NgME NAME OF OPERATOR <br /> ADORES//�8/# J`J` <br /> / EST CROSS STREET PARCEL 8(OPTONN) <br /> CITY NAME STATE LP CODE <br /> SITE PHONE#WITH AREA CODE <br /> ✓BDX <br /> on a a <br /> TOINDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE.AGENCY' <br /> N owner d UST Is a public agency,mnPlae the follow) name d 3 DISTRICTS' 0 FEOEML-AGENCY' <br /> ng: upervhor d tlN4Ion.sm:tion,or office,which operates the UST <br /> TYPE OF BUSINESS O I GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 18 OF TANKS ATSITE E.P.A. I.D.#(nptimal) <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM ,� O G&'t CARE OF ADDRESS INFORMATION <br /> MAILING ORS RUT LAD ES J y� +--{� ✓OoxnIMYaU � INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> cJ !/� M V I I=CORPORATION O PMTNEASHIP EDCOUNTY-AGENCY O FEDENAL#GENCY <br /> C17V NAME ^ STATE ZIP gQDE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bot 0indicate INDIVIDUAL O LOCAL-AGENCY 0 STATE.AGENCY <br /> O 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 it quesgons arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bMdkate D I SELF-INSURED 0 2 GUARANTEE D a INSURANCE O A SURETY BOND <br /> 0 5 LETTEROFCREDIT O B EXEMPTION 0 99 OTHER <br /> III. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 <br /> is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O if.Iy I III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST 01 KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# I�FACILITY* <br /> ED W <br /> LOCATION CO -OPTIONAL CENSUS;A�T# -�,pTIONAC SUPVISOR-DISTRICT CODE -OPipIWL <br /> THIS FORMMUSTBE ACCOMPANIED BY AT-4- <br /> ST LE✓AST(1))ORR�MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOgOR11AN7 <br /> y <br />