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•I <br /> 0Va fS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Fe7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE gb <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PMCELM(OPTN)NAp <br /> IIT S. Sdu ., r r/a a-r <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> a� CA 15- Z0z— —rd(0Y- `/)-rZ <br /> TO INDICATE O CORPORATION D INDIVIDUAL Q PARTNERSHIP Q LOCALAGENCY COUNTY AGENCY STATE-AGENCY <br /> DISTRICTS D FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INOIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM O d PROCESSOR RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIROD, - PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> v�-� Z�9 � — <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> "NE I WITH AREA GOOF <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> s' Gc f�u <br /> MAILING OR STREET ADDRESS / ✓horml O INDIVIDUAL LOCAbAGENCY STATEAGENCV <br /> GLt�lGL-'f ORPJRATION 0 PARTNERSHIP I�COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Su��v—r ps' Lr/ Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS. ✓box 0 indkata OINDIVIDUAL LOCAL AGENCY [-] STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP O COuNrY AGENCY O 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 4 L]-[QJ3 �� <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ bo+bintlicale <br /> FYI SELF INSURED L-]2 GUARANTEE 0 7 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION L-1 N 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 <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANT'S TIT LE DATE MONTHIDAYIVFAR <br /> LOCAL AGENCY USE ONLY <br /> CO?NTV u JURISDICTION# FACILITY# R1 G L / // <br /> JJ 99 I <br /> LOCATION CODE -OPTIONAL ICENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> U / d3n � k <-Y 3 32.3 <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGpk<dNS <br /> 0 0 {C�/O�� FORO033A 16 <br />