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STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD JAN 0 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATIONS ff AMENTA e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE PERMIT/SER <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O T PERMANENTLY CLO ) <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) e <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> D ART nIsmc <br /> ADDRESS NEA EST CROS�S"STREET PpRCELP10PfgNAq <br /> A AQT C EJZO/T a <br /> CITY NAME STATE ZIP CODEITE P ONE r WITH AREA CODE <br /> S-roc kTor.1 io . q5=; CA Zaq 931-08(.0 <br /> BOX <br /> TOINDCATE ACORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> PROCESSOR 5 OTHER RESERVATION <br /> 3 FARM 4 <br /> Q Q � OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> +r u 2AI-0stoo <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S4,La,J 1 9510-(�i1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 17A t <br /> MAILING OR STREET ADDRESS ✓bwbindicata Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> A RT R XCORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALPGENCV <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> k-To 9sa 1 xFi I -pgc,o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓603 bimka Q INDIVIDUAL Q LOCALAGENCY Q STATE-AGENCY <br /> 3 N . ART Zig - XCOflPoNAT ON Q PARTNERSHIP TNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> k ra s a 1 204 1-o to o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4FC> a 0 0 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bIMkY4 Q 1 SELF-INSURED IQ 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT [-16 EXEMPTION W 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.M 11.0 111.D <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAMTURE)MEE(PRINTED&SIGNAAPPLICANTS TITLE DATE M NTH/D,7/YEAR <br /> 10/t/A! <br /> LOCAL AGENCY US L <br /> COUNTY; JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE^^-OP�TIONAL <br /> d� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A 5 <br /> a- I o- 13 � <br />