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STATE OF CALIFORNIA �eoa. e <br /> STATE WATER RESOURCES CONTROL BOARD ci <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A w '� v s <br /> f. o° <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE "�""" <br /> MARK ONLY F--j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L�j T PERMANENTLY CLOSED SITE <br /> ONE ITEM0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRFACILITY NAME NAMEOFOPERATOR <br /> 14� <br /> ADO E ?r GJICLJ[f-•%l,'� NE ST CROSS STREET PARCEL#(OPTIONAL) <br /> • G✓ S�fn �Fa-n �n 0 <br /> CI NA E STACEA ZIP CODE �� SITE PHONE#WITH AREA CODE <br /> 3" <br /> ✓ PDX 5 <br /> TO INDICATE D CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY O COUNTY AGENCY <br /> DISTRICTS STATE-AGENCY 0 FEDERAL#GENCV <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.I(cp#mal) <br /> 3 FARM O 4 PROCESSOR 0 6 OTHER 0 RESERVATION / <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH ARE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING S_TR ETADD E S �L ✓box binEkala 0 INDIVIDUAL EDLOCAL-AGENCYSTATE-AGENCY <br /> Zu�Q I=CORPORATION = PARTNERSHIP <br /> COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NA Ejx ST ZIP COD45'2V? PHONE%WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS W.b Micale 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP ED COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-174 - 2 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binEkau 0 I SELF-INSURED 0 GUARANTEE 1� 3 INSURANCE 0 4 SUR <br /> D 5(ETTEROFCREOIT V,EXEMPTION W OTHER ETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II's hacked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.Fv Ill.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# /Temp-0 JURISDICTION# FACILITY# <br /> LOCATION COD- TONAL CENSUS TRACT# -OUONAL SUPVIW DE -OP77ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTDIS RICT CO <br /> T(1)OR MORE PER APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FCR6633A 5 <br /> J L <br />