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•ie <br /> STATE OF CALIFORNIA w •• `s <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> `.l.OI.M•� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE :: �+�_f' —Ls pm I ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 50 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMR El6 TEMPORARY SITE CLOSURE O i <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME r NAMEOFOPERA .R <br /> ADDRESS Amo IDI jr 4 ` .T. (QOZ <br /> NEAREST CROSS STREET PARCEL#(OPTAONAU <br /> 50\ U) Ke.:t\e ry Lame Nv�c�ws <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lc�a� CA CiS146 hoc# 3 -014t <br /> TOINDI RATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCALAGENCY COUNTYAGENNCY STATE-AGENCY FFDERAL4%NCY <br /> DISTRICTS <br /> TYPE OF allSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(galimaq <br /> RESERVATION <br /> ❑ 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#�+rH AREA CODE DAYS: NAME(LAST.FIRST) $00-2'12-b3aq <br /> Mp'W?'Ge0. oN (2cRl a33 -otv Reo aTri�en,once � (1� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) '$O0 -2.-IZ JDSk -1 <br /> 1\A UN •DLT cuc 33 tai ARcO V\imnf wixNee <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ARCO T G'CS COM n EIA <br /> MAILING OR STREET ADDRESS ✓ bm I'M" 0 INDIVIDUAL 0 LOCALAGENCY 0 STATFAGENCY <br /> 01. <br /> • 100111 Cp CORPORATION O PARTNERSHIP p COUNTY AGENCY = FEDEwuwGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> A <sL Ga. 9 b-101_ 03� -1311010-5 04 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESSI FORMATION <br /> N940 �ro uL COMAn E11tSr <br /> MAILING OR STREET ADDRESS <br /> � 1 �✓,..II bcXII)kd # INDIVIDUAL 0 LOCAL-AGENCY f� STATE-AGENCY <br /> P• • Lia►. `DO.3 L LCORPORATION PARTNERSHIP 0 COUNTYAGENCY O FEDERALAUNCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREACODE <br /> S 1 2- �t � b10-S�1o� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - tl 0 U S O Io <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bpXplbN (�1 SELNNSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 5 IETTEROFCREDIT 0 5 EXEMPTION 0 99 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.❑ IL❑ 1'III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT � <br /> APPLICAN1T'S AME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE M�"`WDAYNEAR <br /> 17J��t �. E �Om `t Ce �a mL►J . l L`L\5 S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FACILRY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE 0 RE INFORMATION ONLY. <br /> FORM A(5-91) FOR0013A.5 <br /> 'co'. `�xdSoA�v�1,T�o Fub,\!ei'd�`� ct �P•0, �o� 200°1 S'�oJl,TOA1 CLL , "�20\ <br />