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• � ee w <br /> r <br /> STATEOFCAUFOFHA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , s <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT E:15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACT E NAME OF OP <br /> -51 <br /> ADORES - NEAREST SS 771 PARCEL a IOPOIaNAp <br /> // <br /> CITU NAME <br /> SC <br /> ZIP C E /y_ SITE PHONE s WITH AREA CODE <br /> T 10 Np ATE O CORPORATION INDIVIDUAL Q PARTNERSHIP D LOCAL-AGENCY (]COUNTYAGENCY' 7O STATE-AGENCY- O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST IS a public agency,conplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 (SAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> / IFINIAN a OF TANKS AT SITE E.P.A. 1.D.a(optvanae <br /> Q 3 FARM 4 PROCESSOR ❑ 5 OTHER 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 a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ,1 box blndicab 0INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION O PARTNERSHIP CWNrY.AGENCY 0 FEDERALAGENCY <br /> CITY NAME 1W I V STATE ZIP CODE 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 ✓ box bin7icMe INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP I3 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]4- -ILLII<17JJ LLL-.I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMicaN 0 1 SELF-INSURED O GUARANTEE =3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREDIT a EXEMPT ON O m 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 SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[=] IL[::] IN.❑ <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(PA INTED a SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION FACILITY a n <br /> LOCATIONE -OPTIONAL CENSUSTRACTa-OPT SUPVIscIR-m trrcorte 32 <br /> 23 . J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B.UNLESS THIS S A CHANGE OF SrTE iwo WkONbmy. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) r:'...,, FOROM MA7 <br />