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' , • • pew' � <br /> STATE OF CALIFORNIA :�' �% <br /> STATE WATER RESOURCES CONTROL BOARD ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 's <br /> COMPLETE THIS FORM FOR EACH FACILITYISrTE `'��•oa"" <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO <br /> ONE ITEM X2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) b <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 4' a <br /> ADDRE NEAREST CROSS STIR ET PARCEL#(OPTIONAL) <br /> CITY NAPE STATE f ZIP DE SITE PHONE WITH AREA CODE <br /> CA <br /> ✓ Box LOCAL-AGENCY TOINDCATE O CORPORATION 0 INDIVIDUAL �PARTNERSHIP 0 LOCAL-AGE 0 COUNTY-AGENCY' STATE-AGENCY' O FEDERALAGENCY' <br /> N owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTORgESEIFINIAN RVADION #OF TANKS AT SITE E.P.A. I.D.#(cp#ma) <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) .HONE#WITH AREA CODE DAY'S: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> ao — aa e �1 0 - <br /> N S: NAME,_.,­­, HONE#WITHAFIE IA CODE N S: N ME T,FIRST) PHONE*WITH AREA CODE <br /> ( ( <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> - fh2 Zea pin <br /> MAILING OR STREETADDRESS ✓Cos blMiwte = INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> U �j CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODEPHONE AREACODE <br /> _s-f o ao#WIT 3-ao <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW SNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binEbM# Q INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE x WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bpr blMkaM Q 1 SELRINSUflED l�2 GUARANTEE E-17 INSURANCE D 4 SURETY ND <br /> (FTfEfl OF CREDIT O 6 EXEMPTION OTHER W44ef <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 /> CHECKONE BOX INDICATING WHICH ABOVEADDRESS SHOULD BE USEDFOR LEGAL NOTIFICATIONS AND BILLING: I.[::] II. 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 2 G I] a <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP770MAL <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) FOROD731A7 <br />