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tgoVA tg <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION [�j 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT j —1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME <br /> {O,.F�OPERATOR <br /> ss It, <br /> ADDRESS h NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA :7?'j 3o�t~ t33tp-31$1 <br /> I` ✓ BOX < . <br /> TO INDICATE I�ORPORATION E:1 INDIVIDUAL (� PARTNERSHIP [� LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-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 Q ✓ IF INDIAN 8 OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> g! RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDSLnbo <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH REA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G r �' g- (cs hvr '4 �35 <br /> NIGHTS: NAME(LT, IRS t 1 PHONE•WITH AREA DE �� NIGHTS:NAME(LAST,FIRS PHONE t WITH AREA CODE <br /> M11LL77 13hfzis <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAI G R ADD ESS ✓ box bIndicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ICORPORATION (] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> t � <br /> CI AME STATE ZIP C E PHONE 1f WITH AREA CODE <br /> &k�Qi onG 0 LA SFS <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAi�OF OWNER CARE OF A DRE IN ORMATION <br /> V- co oc <br /> MAI IN OR STR ADDRE S ✓ box b indicate 0 INDIVIDUAL I� LOCAL-AGENCY 0 STATE-AGENCY <br /> 7� X.CORPORATION Q PARTNERSHIP COUNTY-AGENCY Ell FEDERAL-AGENCY <br /> CITY hLAME STATE ZIP CODE PHONE i WITH AREA CO <br /> DM <br /> \4oz <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - QJ l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY80ND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION 99 OTHER <br /> VI. EGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHEC E BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ IL a III.Ej <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 ONTH/DAY/YEAR <br /> - rn �� a <br /> LOCAL A ENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <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 FORMP THE LOCAL AGENCY IMPLEMENTING THE UNDERGRgMSTORAGE TANK REGULATIONS <br /> FORMA(3193) FOR00f13A-R7 <br />