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.. !`601JF Cy c <br /> STATE OF CALIFORNIA �� a <br /> STATE WATER RESOURCES CONTROL BOARD F 1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE —71 <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT �58 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ACME= , NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3 9CI NAME STATE ZIP CCtD SITE PHONE#WITH AREA CODE <br /> G q-&— CA <br /> ✓Box <br /> TO INDICATE O CORPORATION = INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY 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 F--j 1 GAS STATION F-1 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME-(LAST'FIRST) P NE#WITH AREA COW NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Ii � ( <br /> 11. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boz b lyd cafe = INDIVIDUAL (� LOCAL-AGENCY � STATE-AGENCY <br /> 1 Q CORPORATION = PARTNERSHIP (]COUNTY-AGENCY = FEDERAL-AGENCY <br /> CI STATE ZIP CODE PHONE#WITH AREA CODE <br /> C, CAJ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br />: NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 42 4A4 <br /> MAILING ORSTR ET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> V.BOA ED.OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questio�qs arise. <br /> TY(TK) HQ 4 4- - I� T tUb µ�wfi� 1 (4 �NO-e,7` -ti,n� <br /> / b ` o-y' I ) ?K't, a'�t 4 J ay <br /> V. PETROL ST F ABILITY IST ET ) IDENTIFY THE METHOD(S) USED <br /> boxbi t. -,,, 1 SELF-INSURED G A 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION E:1 99 OTHER <br /> VL 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 90X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L H.El III. <br /> 11�ws 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> L4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FOR UST BE ACCOMPANIED BY AT LEAST(1)0 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 REGULAT00 <br /> FORMA(3193) F0R=3A-R7 <br />