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• • eeWe [ <br /> f <br /> e <br /> STATE OF CAUFOf#LA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3 <br /> , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `"'•°""'� <br /> MARK ONLY O t NEW PERMIT F_­l 3 RENEWAL PERMIT Q 5 CHANCE OF INFORMATION Q 7 PERMANENTLY CLOSED S1TE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 08A OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> dpi ��h �� � NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> , <br /> CRY NAME STATE ZIP CODE TE PHO E WITH AREA CODE <br /> 1i0� CA 9� 1-11 i��g 168—S %r <br /> BOX l�CORPORATION E3 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Ej COUNTY-AGENCY' O STATE-AGENCY' O FEDEMLAGENCY' <br /> TOINDICATE DISTRICTS' <br /> •N owner of UST Is a public agency.complete the following:name W Supervbor of division,section,or otlics which operates the UST <br /> I IF TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR 0 pESERVATDION IAN #OF TANKS AT SITE E.P.A. I.D.a(npflmaq <br /> Q 3 FARM I� 4 PROCESSOR �6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV AME(LAST,FI Sn PHOryryE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (�� S�9S <br /> NIGHTS: NAME UST,FIRST) PHO E#WrTHAREACODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> ( 3GF— 7,-_7/z) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING OR STREET ADDRESS box biMkale 0INDIVIDUAL OLOCAL-AGENCY ffj STATE AGENCY <br /> 7O 9q _�. Ste' Lj j_ CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CRY NAME I STAIF, ZIP cc PHONE a WITH AREA CODE- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER., I CARE OF ADDRESS INFORMATION <br /> uDTJ G(/r/� �lG <br /> MAILING OR STREET ADDRESS <br /> box blr'�as Q INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> 1 O /3 p✓ /�v pORATION PARTNERSHIP 0 COUKIYAGENCY FEDERALAGENCY <br /> CIN NAME _ /� STATV ZIP COgF PHONEa)NITHAREACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlkLe O t SELF-INSURED =12 GUARANTEE Lj 3 INSURANCE O4 SURETYSON0 <br /> D 5 LETrEROFCREDIT O a EXEMPTION O ss 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 /> //(( <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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(PRINTED831GNED) OWNER'S TRLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# LT <br /> 17 1'X <br /> LOCAJION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SU7�PVISSQR-DISTRICT CODE -OPTIONAL <br /> O GC(�J <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 FOR0033AR7 <br /> FORM A(393) 0 1191 <br />