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• !ts oe e c <br /> n 9 <br /> STATE OFCALIFORMA � 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ! _. <br /> l�IIbR�"� <br /> COMPLETE THIS FORM FOR EACHFACILRYISITE <br /> ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT El5 CHANGE OF INFORMATION ❑ ] 'PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM ❑ 2 INTERIM PERMIT E::] 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE P <br /> I. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> OF OPERATOR <br /> DBA OR FACILITY NAME N7 / C� ;: �tPARCELCO <br /> �' yt/l5NEAREST CROSS STREET PTIONAy <br /> ADDRESS ) /J� <br /> 13,S/6 Cw�+ I C STATE ZIP CODE SITE PHONE t WITH AREA CODE <br /> CITY NAMEG / CSA <br /> Box O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY E3 COUNTY-AGENCY' �STATE-AGENCY' O FFDEPAbAGENCY' <br /> TOINDICATE DISTRICTS' <br /> If onner el UST Ie a Public agency,complete the lollowing:name of Supervkor of tlNieIon,eecUon,or office which OWhe98 SOF TANKS AT SITE E.P.A. I.D.a(optional) <br /> TVPEOFBUSINESS L t GAS STATION ❑ 2 DISTRIBUTOR / RESERVATION 2 <br /> ❑ 3 FARM 4 PROCESSOR ,Pfj ,' OTHER OR TRUST LANDS _7 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE S WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONES WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE ADDRESS INFORMATION <br /> NAME � LM / L_ O �r� <br /> �� ✓borbI ala T7� L_j <br /> MAILING OR STREET ADDRESS O INDIVIDUAL ED LOCAL-AGENCY <br /> O FEDERAGENCY <br /> �CORPORATION � PARTNERSHIP � COUNTY-AGENCY � FEDEIU4AGENCY <br /> L d` STATE ZIP CODE- PHONE%WITH AP_gCODE <br /> CITY NAME ( it �y Z y((] A L/ 7 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> S4 ML <br /> ✓ box biMirate Q INDIVIDUAL 0LOCAL-AGENCY OSTATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> �CORPoRATON O PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE S WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> =T SELF-INSURED O 2 GUARANTEE E:1 3 INSURANCE O 4 SURETY BOND <br /> ✓ box to bullcme O 5 LETTER OF CREDIT 6 EXMPTION 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 the d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> .❑ L NI.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNERS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY 0 <br /> COUNTY It JURISDICTION a FACILITY <br /> F3 11 �m o a <br /> 3 Z <br /> SUPVISOR-DISTRICT CODE -OPTIONAL 3,31 y <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL 23� <br /> © � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION. NL :. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOIi0031AA7 <br /> FORMA(3G3) �Zl: (IIh I <br /> I I <br />