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.4.00. . <br /> C <br /> STATE OF CALIFORNIA : 0`; <br /> STATE WATER RESOURCES CONTROL BOARD s " <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� 'e <br /> �. r!„ o' <br /> ro <br /> °4noMN,. <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> APLo A Af ,u r N[ J44� <br /> ADDRESS5 S - I!! D"`�, �WE <br /> CITY NAME ZZ <br /> CROSS STREET PAXCELaIOPFKINAU <br /> JB' C-/]' /�-� STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> p� CAv Box <br /> R' �O (Foal X68 - 786 <br /> TO INDICATE CORPORATION Q INDIVIDUAL C-1 PARTNERSHIP C]LOCAL-AGENCY 0 COUNTYAGENCY Q STATE-AGENCY [:1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION i OF TAu'e AT SITE ,Es.P.A. L D.i(gptAaTaO <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 6141 000 Qoc( �Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE AYS:NAME(LAST,FIRST) `� /�/ —�/O� <br /> H<Gi7f�vGi�i4Np 2PR)S68-78'6 0 �1 v. 4A164 - (Zl 7 L C <br /> NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> AAco A?o7�GTS e-0 <br /> �MAILING OR STREET AWRESS,�Y1 - ,,a � �•�Y ��✓/bmb WleaN D INDIVIDUAL I]LOCAL-AGENCY ED STATE-AGENCY <br /> lei NPS /1V�Y S L_fGONPORATION p PARTNERSHIP COUNTY-AGENCY p FEDERAL- <br /> AGENCY <br /> CITY NAME STATE ZIP COOF, PHONE i WITH AREA CODE <br /> fit lcf .4.Q G� 4 'l03 C�/rsJ Sir- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OFOWNER CARE OF ADDRESS INFORMATION <br /> &O /dA40p eo <br /> MAILING OR STREET ADDRESS ✓ box bindcM ED INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Z�'O �pyivH or ORPORATON ED PARTNERSHIP CD COUNTY-AGENCY CD FEDERALAGENCY <br /> CITY ` C,, STATE d Z;17 _7P2. �HIO'etI�E:1 ITN AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - (} O D O 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J <br /> In,bintlbm 0 I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 1 SUBETYBOND <br /> 0 5 LETTEROFCREDIr (]B EXEMPTION Q N 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.❑ II.[�Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION x FACILITY a <br /> LOCATION CODE -OPTIONAL CENSUSTRA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> OZ 23. S10 3Zo E.T 6 Z6 R <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 /> FORM A(5.91) FORW33A"5 <br /> ,4'_ -� ,\ <br />