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Pe'OUR es <br /> STATE OF CALIFORNIA ho-• ° <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a�� 40 <br /> •r�I IFOR N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY E"I i NEW PERMIT F73 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED(S+I�TE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE X <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) u <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C-\/12C>ij <br /> ADDRESS NEAREST CROSS STREET PACEL#(OPTIONAL) <br /> Io �/ �W RI�� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> MAI_W-me� CA <br /> TOINDIC TE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = I GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> m 510 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> G btlJA,A pie 540 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR'STREET ADDRESS ✓ box toindicate 0 INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> 2410 C/ IBJ�1^ CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME <br /> TATS SZIP PHONE#WITH AREA CO <br /> lU (Q2I <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /v'l�QDE <br /> r��/�� � <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> iC <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q 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) HOF 4 -161151 q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED (]2 GUARANTEE 3 INSURANCE 0 4 SURETY 30ND <br /> D 5 LETTER OF CREDIT 0 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 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.El III.7 <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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> tzl_-�L — I 'mj>3 I 4��s 0 — <br /> LOCAL AGENCY USE ONLY r Aj5 <br /> COUNTY# JURISDICTION# FACILITY# C HCvA If <br /> J <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © � 3 2C- /0 <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. J <br /> FORM A(5-91) FOR0033A-Sl <br />