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417 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O t NEW PERMIT a 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT [__1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME FOPERATOR <br /> e; S tem- 5'e_ <br /> . <br /> ADDR SS NE�A�R€ST CROSS STREET PARCEL#(OPTIONAL) <br /> 15,36 E <br /> CITY NAME STATE ZIP E SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 11 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 a t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY NAM (LAST,FIRST) PHO E#WITH EA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S - 0`� r <br /> NIGHTS: NAME(LAST,FIRSTf PHOW#WITH REA CODE NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbindcate INDIVIDUAL LOCAL-AGENCY STATE- <br /> AGENCY <br /> D CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> , <br /> MAILING OR STREET ADDRESS ✓ box b indicate <br /> INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [41_4 - o 1.114 155� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box toindicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION Ejj 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: 11%] <br /> II.❑ <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) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY '" <br /> l <br /> COUNTY# I I JURISDICTION# FACILITY# 3� <br /> LOCATION CODE -OPTIONAL CE S TRACT# - ONA SUPVISOR-DI TR T CODE -OPTIONAL <br /> oe9 '0 <br /> THIS FORM MUST BE ACCOMPA T(1)OR 4ORE 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 REGULATWNS <br /> FORMA(3/93) FOR0033A-R7 <br /> I-3D-G l �k - <br />