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' eeeoon � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD sy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION—/7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF LyTY NAME %h� NAME OF OPEj;;T <br /> ADDRESS/� r _ o a '71/V_ //� NEARESyQ_RVSOSS�TRfcET PARCEL#(OPTIONAL) <br /> CITY NAME W U /wl v/1 STACT6AK ZQIP/OOeO'E SITE PHONE#WITH AREA CODE <br /> ✓ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL E]PARTNERSHIP Q LOCAL-AGENCY O COUNTY AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANIAT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> OR U <br /> 0 3 FARM 4 PROCESSOR 5 OTHER 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 /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME O C) /t G / CARE OF ADDRESS INFORMATION <br /> MAILINGOR ST$E ADDRESS /`/!qJ�#nl J I ✓ bindione Q INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> 53 (l f�C✓j/'y COflPoRATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STAJj - ZIP CO PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C114 <br /> NAME OFO NE_R �,,�p� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMicaw INDIVIDUAL E:] LOCAL AGENCY STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP Q COUNTY AGENCY Q FEDEMLAGENCY <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-F4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IoiMicale I SELF-INSURED 0 JAARANTEE 3 INSURANCE 0 0 SURETY BOND <br /> 5 LETTER OF CREDIT EV6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.11 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION COD TIONAL CENSUS TRACL -OPTIC LL SUPVISOR-DIST ICT CODE -OP <br /> o. <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(5.91) <br /> FOflW37A5 <br />