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• 'ayoVn � <br /> STATEOFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BECOMPIL ED) <br /> DPA OR FACILITY NAME NAME OF OPERATOR <br /> TT) <br /> ADDRESS NEAREST CROSS STR PARCE(O(OPrIONAW <br /> 0 til/. GD/,? ✓ /`�vTG�� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �= CA 952 oev Zo i <br /> TO DI RTE CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> M owner d UST la a public agency,mrrplde the IdIPYAng:name d Superviord DISTRICTS' <br /> ,O"Ionsection,or o#ice which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR ' IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(apdaI <br /> 0 3 FARM 0 4 PROCESSOR 0 RESERVATION <br /> O 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,FIRST) PHONE#WITH AREA CODE <br /> ,d 9 -Zoe <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BECOMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i A o <br /> MAILING OR STREET ADDRESS �-- ✓boa biMkab OINDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> O SO 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �3-201 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING OR STREE ADDRESS <br /> ��/ ✓boa bbbkM C:] INDIVIDUAL 0LOCAL-AGENCY =STATE-AGENCY <br /> ✓ a7'/'s {� D CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> STt�o�7bF o9 G7 D ��13-zm, <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 /> ✓boabkWkate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> D 1 SURE Y BOND <br /> O 5 LETTER OF CREGT O 6 EXEMPTION D 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.= III. <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 a SIGNED) OWNER'S TITLE DATE MONTWDAY%EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL JC/ENSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o7 SUs.YV I 32a <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) • • FOR00T31g7 <br />