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U. <br /> STATEOFCALIFORNIA <br /> N STATE WATER RESOURCES CONTROL BOARD W 4a 2 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 14! <br /> COMPLETE THIS FORM FOR EACH F ITY/SITE °'(wom0'' <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE VA �` N <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 'Zed' - 3.3.3/3 <br /> ✓ BOX <br /> CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> It 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 L:;;,'1'_GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN Ix OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -1c "Zq' z -33/ -,-e)C/ - G- 2-7S <br /> NIGHTS: NAME(LA T, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> Z <br /> �c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ell <br /> MAILING OR STREET ADDRESS ✓ ndicate 0 INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> 67 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 3u <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 1-7— CARE OF ADDRESS INFORMATION <br /> IS-N'r-e G-0 <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE _7CODE 7PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4 4- -I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓ box b indicate 0 1 SELF-INSURED O 2 GUARANTEE EM,19URANCE P 4 S#RETY BOND <br /> 5 LETTER OF CREDIT D 6 EXEMPTION EV90 OTHER -S <br /> " zhAd&OA <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch ked. <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 8 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 REGULATKNIS \_ <br /> FORMA(3193) � \ � <br /> 1 ,lam <br />