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STATE OF CALIFORNIA r 'o <br /> STATE WATER RESOURCES CONTROL BOARD W md; ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> 14 s COMPLETE THIS FORM FOR EACH FACILITY/SITE �'�•aRN`' <br /> MARK ONLY 0 1 NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F ILITY NAME NAME OF OPERATOR <br /> UAIOc,A L- <br /> ADDRESS / NEA ST CROSS STREET PARCEL If(OPTIONAL) <br /> CITY NAMESTATE ZIP CogSITE PHONE#WITH AREA CODE <br /> rgv.,lS�� CA <br /> C!3 <br /> TO INDICTE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' 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 1 GAS STATION 0 2 DISTRIBUTOR = ✓ IF INDIAN #OF TAN 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 NTAC T PERSON SECONDARY •optional <br /> DAYS: NAM (LAST)FIRST) PHONE#WITH AREA CODE DAYS:NqM (LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGH S: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> !�' v G —077 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 0 of of= �4G_ L <br /> MAILING OR STREET ADDR SS ✓box b indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> dt7G GcfOt7 (]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMC STATE ZI� � PI�i(VICODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) J <br /> NAME OF OWNER CARE OFADDRESS INF RMATIO� <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> � =CORPORATION Q PARTNERSHIP COUNTY-AGENCY (]FEDERAL-AGENCY <br /> CIN 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDindicate 1 SELF-INSURED 2 GUARANTEE [] 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: 1.D it.= )5 <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY If JURISDICTION# FACILITY# <br /> Ui I I I 151 <br /> LOCATION CODE -OPTIONAL CENSUS TRA T# -OPTIONAL SUPV_ISOR-DISTRICT CODE-OP77ONAL 1212 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERW APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 015,,1►, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM <br /> FORM A(3193) 0 0 oc� M-Rl <br />