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yOVF <br /> STATE OFCALIFORWA ^� •. °i <br /> STATE WATER RESOURCES CONTROL BOARD i o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> �IfOFM•- <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF:INF:ORMATION O 7 PERMANENTLY CLOSED SI <br /> ONE ITEM 2 INTERIM PERMIT Q < AMENDED PERMIT S TEMPORARYCLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITV NAM9 <br /> N/ NAME OF OPERATOR <br /> ADORES <br /> 9L/ VG NE RESTCROSS ST EET PARCELi(OPIONI <br /> CITY NAME /C <br /> STATE ZIgP WGgE �7 TE P NE i WITH AREA CODE <br /> ✓ BOX C14 // ZJ / Z7'-5EA <br /> TO INDICATE 0 CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCYCOgMy#GENCy <br /> 'It owner of UST is a public agency,complete the following:name of SupeI of d"Jon,eecibn IS RIOToffice which operates the UST STATE-AGENCY' ED FEDERAL-AGENCY' <br /> TYPE OF BUSINESS O GA <br /> T S STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(golioneQ <br /> 3 FARM = a PROCESSOR 5 OTHER 0 RESERVATION <br /> OR TflUSTLANOS <br /> EMERGENCY CONTACTPERSOH(PRIMARY) EMERGENCY CONTAC bjco.ON (SECONDARY)-optional <br /> DAYS: NA E( ST,FIRST) HONE i WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER IN ORMATION- MUST E COMPLETED <br /> NAME <br /> �^ �j/ n CARE OF ADDRESS INFORMATION <br /> MAILIN STREET ADDRESS r7• - <br /> p ' 30 ✓OoxblydbaN 0 INDIVIDUAL LOCAI.AGENCV =STATE-AGENCY <br /> CITY NAME 0 CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY O FEDERAL AGENCY <br /> STATE ZIP CODE PHON aWITH AREA CODE <br /> Z3 7Z�-4S <br /> III. TANK OWNER I F RMATION-(MUST B COMPLETED) <br /> NAME OF OW R CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS ✓ box bindicate <br /> �Q ZA" D INDIVIDUAL 0 LOCAUAGENCY O STATE-AGENCY <br /> CITY NAME 0 CORPORATION 0 PARTNERSHIP O COUNTY AGENCY 0 FEDERAL-AGENCY <br /> —� STATE ZIP CODE HONE 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 q q- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED - — <br /> ✓box bindbale 0 1 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE <br /> O 5 LETTEROFCREDIT D 6 E%EMP 10N D SB OTHER D SURE YBOND <br /> VL 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: <br /> L D il. NIL O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND RRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE <br /> DATE MONTWDAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION At FACILITY• <br /> LOCATION CODE -OPilONAL CENSUS TRACT -OPTIONAL <br /> BUI+VISOR-DISTRICT CODE -OPTAONAL <br /> Z3 <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 /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO*�TORAGE TANK REGULATIONS <br /> FORD M-117 <br />