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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD $.,�� a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY [K 1 NEW PERMIT F__] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT [::] 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> -T a rn f A s k <br /> ADDRESS NEAREST CRO STREET PARCEL#(OPTIONAL) <br /> III S Fe- ,D&I-bole W We L05 DC7- <br /> CITY NAME STATE ZIP COD SITE PHONE#WITH AREA CODE <br /> CA <br /> VI BOX <br /> TO INDICATE D CORPORATION NDIVIDU L =PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY' (]STATE-AGENCYE�] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If 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 ®/GAS STATION 2 DISTRIBUTOR 0 RESERVATIONINDIAN <br /> IN OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS Ca Q n, ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS:,N/�ME(LAST,FIRST) PHONE WITH AREA CODE <br /> —C l►1/ ✓- O 2 -e -2- <br /> NIGHTS: <br /> NIGHTS: NAMF_(LAST,FIRST) •_ PHONE#WITH AREA CODE NIGHTS: AME LAST,FIRST) PHONE#WITH AREA CODE <br /> t;L <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P, 1q70 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST ZIP CODE PHONE#WITH AREA CODE epi jL/I <br /> bG1 - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 5� f�CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST TE ZIP CODE PHONE#WITH AREA CODE <br /> �1;z V51 2 " 1- Z <br /> IV.BOARD OF EQUALIZATION UST STO AGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - C Ia 1,t <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 1 SELF-INSURED i1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION 99 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.[:] if.�III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIG OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> i c_ IIsi _ ; ' 7- 31 -55— <br /> LOCAL AGENCY USE/ONLY <br /> COUNTY# JURISDICTION# FACILITY#,�te d <br /> m I 1A3 3 <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 INFORMA Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FDRpMMA7 <br />