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1* o e <br /> STATE OF CALIFORNIA ^. <br /> STATE WATER RESOURCES CONTROL BOARD . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> C41,OPN <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS�!/± <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAQgFg01tJTY aFu,1FCILITY#02479 NAM EOFODanPERATOR <br /> SlsneroZ <br /> ADDR66S7 Pacific Ave NIKPEFrSW4OS• $$THEET PARRCPELL#(O�PFT•IO�NYAL) j� <br /> CldtitocE kton STATE I�ZIOPaCaODF65207 10}j-a`JG-4`JTj•I'J REA CODE <br /> CA y �I <br /> ✓ BOX <br /> TOINDICATE C19brORPORATION Q INDIVIDUAL E71 PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY D FEDERAL-AGENCY <br /> �p DISTRICTS <br /> TYPE OF BUSINESS Ia 1 GAS STATION ❑ 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE .P.A. I.D.#(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ E <br /> OR 4 PROCESSOR 0 5 OTHER TRUST LANDS 4 AL 930 193 448 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> SILVA, LARRY 1-206 442-7160 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> BP Emergency Desk 1-800-274-3572 PHON9.1 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA CARE Oil Company CAREOFAYa er P�mico <br /> MAILING OR STREET ADDRESS ✓ box 0intlbate E:1 INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> 10000 Lakewood Blvd CORPORATION = PARTNERSHIP ]COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Downey CA 90240 213-923-9876 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Tosco Northwest Prop. I, Inc. LARRY SILVA <br /> MAILING OR STREET ADDRESS ✓bozblMicate L-3 INDIVIDUALI� LOCAL-AGENCY ED STATE-AGENCY <br /> 601 UNION STREET, STE 2500 CORPORATION C:1 PARTNERSHIP O COUNTY-AGENCY E::] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> SEATTLE WA 98101 1-206-442-7160 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. _ <br /> TY(TK) HQ F4-[4-]- <br /> 0 3 6 2 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate )CIC 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 d SURETY BOND <br /> 0 5 LETTEROFCREDIT D 6 EXEMPTION C-199 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.❑ it.❑ <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> CHESTER BENNETT RETAIL ENGINEER <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# v lyj� <br /> 13y I 2� 111 <br /> LOCATION CODE -OPTI CENSUS TRI -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Z ` Zi'31 <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) FOR0033A.5 <br />