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• • ' 'llaJP <br /> - C <br /> Y � <br /> STATE OF CALIFORNIA '4 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> CPt iIOPY�P <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> MARK ONLY 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BECOMPLETED) <br /> DBAO FACILITYNAME <br /> ! E_AREST ROSS STREET 4, PARCEL#(OPTIONAIJ <br /> ADORE$ ^ ^ VKA All cCJ'Cr.I'lJ• <br /> d( d STATE ZIP D� SITE PHONE#WITH AREA CODE <br /> CITY NAME CA <br /> ✓ Box ppp���,,, INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY l3 COUNTY-AGENCY' ED STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE I�LCAflPORATION DISTRICTS' <br /> •B caner d UST is a public agency.mmplete the iollawing:name of Superveor of dWkbn,ceclbn,a office whk al"the UST <br /> IF(INDIAN #OF TANKS AT SITE E.P.A. I.D.#(ePMnel) <br /> TYPEOF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST MOS <br /> EMERGENCY COMACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OAVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST E� 1P/IED CARE OF ADDRESS INFORMATION <br /> A E / <br /> r, r lam• I NZO !/p°a blMkale INDIVIDUAL =LOCAL RGENCY =STATE-AGENCY <br /> MAI G OR STRE ADDRESS 0 CORPORATIONO PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> SWE,L ZI DEO ONE# TH�REA CODE <br /> CITY NA '(- l/Y^ <br /> K III. TANK OWNER INFORM ION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> —- - ✓ borbindkM ED INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> MAILING OR STflEET ADDRESS <br /> ED CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> -- — -- STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]-4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Ij I SELF-INSURED 0 2 GUARANTEE 0 9 INSURANCE OTHER <br /> 0 6 SURETY BOND <br /> ✓ boa bgdkate 0 5 LETTER OF CREDIT l3 6 EXEMPTION ID <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: 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 /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'STITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> OJURISDICTION# FACILITY# <br /> �CIG��LU_TINL[TY# F= L-J�+/a'�-' <br /> rLOCATION�GDE -OPTIONAL CENSUS TRACT#-f1P7TQ`NAL <br /> SUPVISOR-DISTRIC -OPTAONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONSr , RA0033A RT <br /> FORM A(3W) • <br /> I <br />