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� y ,o�A e <br /> STATE OF CALIFORNIA �� <br /> W� <br /> STATE WATER RESOURCES CONTROL BOARD w��, o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> � . o <br /> ONN�\ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SFFE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> SGn �09I d�A <br /> ADDRESS � ' NEAREST CROSS STREET PMCEL#(OPFpNAU <br /> 52 r lcA� <br /> CITY NAME STATE IF CODE SITE PHONE#WITH AREA CODE <br /> CA 5.3 <br /> 'I Ox <br /> TOINOX CORPORATION INDIVIDUAL Q PARTNERSHIP 8' OUBQ LOCAL-AGENCY NTYAGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> Q Q <br /> DISTRICTS <br /> TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR E R SERVATION ;1 OF TANKS AT SITE E.P.A. I.D.a(optional) <br /> �—t3 FARM Q / PROCESSOR Q 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) <br /> 4In0,k �"% - $ S <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 0 �� CARE OF ADDRESS INFORMATION <br /> S 1 , Co l le� <br /> MAILING OR STREETADDRESS ♦ `� Ixxbimtl Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> _ S 5 , P ` Q CORPORATION Q PARTNERSHIP ED COUNTY-AGENCY IQ FEDERAL-AGENCY <br /> CITY NAME �J II STATE ZIP CODE PHONE#WITH AREA CODE <br /> J -SIC i'O✓] SOZO7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ lox b INKale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO [4T41-[ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eox bi�Mbale Q 1 SELFINSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SUREFY BOND <br /> Q 5 LETFEROFCREDIT Q 6 EXEMPTION Q W OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= 'ZrIIII. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 <br /> El-L] 4 0 <br /> -OCATIONCODE OPNONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �� <br /> Ill 23 2"3 V C <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(12-61) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /// FOR0033A R6 <br />