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o . <br /> STATE OF CALIFORNIA � `' <br /> STATE WATER RESOURCES CONTROL BOARD W +A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�r <br /> C <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DEI OR FACILITY N ETQ \(J n NAME OF OPERATOR <br /> Po fa-lo�an�� W�'.n <br /> AD pF,S_S/ �• I 32 I ' 1,1 NE EST CROSS,?117 1 PMCELA(OPfKINAU <br /> CITY/NG✓A,NEIVAV/1GI/!/l1r/1�I/ W STATE GZIP 5Z03 SITE PHONE#WITH AREA CODE <br /> ✓ WX CORPORATION I� INDIVIDUAL 0 PARTNERSHIP E] LOCAL-AGENCY (]COUKYAGEWY Q STATE AGENCY I1 FEDERAL-AGENCY <br /> TOINOICATE DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN❑ RESERVATION A OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM l) 4 PROCESSOR 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) PHONE a WITH AREA MnP <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> H <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM { CARE OF ADDRESS INFORMATION <br /> MAILING OR STREI/ET ADDRESS L, �a<�/ `� IW.N O INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 20 �LJ6�l 6n J b (J(/I CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CST <br /> /n•�/�'n ^T STATEZIP E / PHONE#WITH AREA CODE <br /> \ [ l" cit S <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Dox 0Imam INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNTYAGENCY 0 FEDERALAGENCY <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) HQ 4 4 0 3 2 -2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ tm 0intlkate I SELF-INSURED [::]2 GUARANTEE (] INSURANCE 0 4 SURETY B3ND <br /> 5 LETTER OF CREDIT E:I 6 EXEMPTION �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 6,pfiecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11. - III.❑ <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ig <br /> ® �imErS � 28 1 <br /> LOCATION CODE-OPTIONAL (CENSUS TCT#:Opj10S1AL SUPVISOR-OITRIC CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATTLLEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FCR6033A-5 <br />