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mill <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 L NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ] PERMAN <br /> ONE REM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT O & TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITYNAME NAME OP ATOR /1 <br /> A DDR SS - NE S CRSS STREEZ PMCi(OPTIONAL) <br /> CITU NAME STATE ZIP C SDS_ / SITE PHO�JE WITH�C,O`DF� <br /> r� CA •� 1lJ `lf�/s J <br /> ✓ RPORATION O INDIVIDUAL I�PARTNERSHIP � LOCAL-AGENCY <br /> TO INDICATE DISTRICTS' Q COUNTYAGENCY' a STATE-AGENCY' D FEDERAL-AGENCY' <br /> X owner of UST Is a public see ,oornplete the following:name of Supervisor of division,section,or oaice which opetates the UST <br /> TYPE OF BUSINESS rt GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(garmal) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS'-NAMF(LAST,FIRSDA { PH NEa WITH AREA CODE DAYS: NAM ST,FIR T) PHONE#WITH AREA CODE <br /> /� <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME WT.FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /n/ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ' �f ✓ boa blMkab INDIVIDUAL O LOCAL AGENCY ED STATE-AGENCY <br /> Js S/mss-a*�V IN CORPORATION O PARTNERSHIP Q COUNTY,AGENCY Q FEDERAL-AGENCY <br /> ClT'N E STATE ZIP CODE PHONE a WITH AREA CODE <br /> � <br /> X36 6 r _ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAM.I�.I--TOWNER / CARE OF ADDRESS INFORMATION <br /> U— <br /> MAILING <br /> ''O7R�STREET ADDRESS p''�( ✓ boob kale 0 INDIVIDUAL ED LOCALAGENCY I� STATE-AGENCY <br /> D / — c�L VL/L ORPoRATION O PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME 1STATE 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bow birdbale O I SELF INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT &EXEMPTION D gA 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: 1.0 ll.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�O�U�NNTTYY# JURISDICTION• FACILITY it <br /> LOCATION CODE -OPT�L4L CENSUS TRACT OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -� - � . / <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 /> FORM A(393) • FOR=MA7 <br />