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STATE OF CALIFORNIA +o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,> <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °�^�^"`• <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI <br /> ONE REM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACT TY N E NAME F RATO <br /> ADD! NEARS OSS T 4EET PARCEL 0(OPTIONAL) <br /> CITYN57 - ( STATE ZIP SITE PHONE a WITH AREA CODE <br /> "(9/1/��i/7/„1 LV-7MJi t CA <br /> TOOIN <br /> Box <br /> INDICATE ED CORPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner d UST Is a public agency,complete the following:narre of Supervisor of division,section,Or ofiico which Operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR " IF INDIAN a OF TA T SITE I E.P.A. I.D.a Topaoral) <br /> ❑ RESERVATION <br /> ❑ 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ./ bUbindiate ED INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP COUKrY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME AANA- 04 STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0Indbab 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 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 F4-T4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL PONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓bas bindbeta L-9 1/LF—INSURED O 2 GUARANTEE O NSURANCE0< RETY BOND <br /> LW LETTER OF CREDIT O 6 EXEMPTION sS OTHER <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 6 SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY If <br /> LOCATION CODE -OPTIO CENSUS TRACT -OPTIONAL 1. SUPVISOR-DISTRICT CODE -OP <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHAAGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(193) FO <br /> � • <br /> i <br /> I( rK�4 <br /> e <br />