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/� 1 • ` + � eCyOJM t <br /> Y STATE OFCALIFORWA c� <br /> " o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �'4nOn♦�� 1�/! <br /> COMPLETETHIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) s,( <br /> DBAORFAGI ITYNAME NAM OPERATOR <br /> ADDRESS NEAR TCROS STREET _ PMCELA(OPFIONAL) <br /> 11//OO�/ C 11,W76e s. J//A.T/As/YY <br /> CITY NAOD� <br /> STATE ZI fp �o jNE#WITH AREA COE� <br /> TO DBOXICATE CORPORATION NDIVIDUAL E-1 PARTNERSHIP I�LOCAL-AGENCY <br /> OCAL- G NCY O COUNTY-AGENCV STATE-AGENCY FEDERAL AGENCY <br /> DISTRI <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(apfxaTaq <br /> RESERVATION <br /> O 3 FARM 0 0 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: T, IRS P Ea WI NARFaA CODE DAYS: NAME(LAST,FIRST) <br /> 000 9 <br /> NIG TS: NAME(LAS.Fr NIGHS: NAME(LAST,FIRS ) _ <br /> `7PHONE Z1ITHARFAQnTF <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED Aleal OaY-t, <br /> NAM CARE OF ADDRESS INFORMATION <br /> � ON mH <br /> MAIUNG OR STREET ADDRESS ✓hoc biMbri INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> 6,3 /3 ' 0 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY <br /> AREA <br /> FEDERAL-AGENCY <br /> CITY BTAjE_& ZIP CODE Nlel I✓ 7i—{M C a <br /> Ill. TANK OWNER INFORMATION'-(MUST BE COMPLETED) <br /> r//1�i} <br /> NAME OF OW NF8—a� CARE OF ADDRESS INFORMATION <br /> S� <br /> MAILING OR STREET ADDRESS ✓ box b WTI% O INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> CORPORATION O PARTNERSHIP EI]COUNINAGENCY FEDERAL#GENCY <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 queslions arise. <br /> TY(TK) HO L4 T 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box W indicate I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I, II.O III. <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&SIGNATURE) PPLICANTS TITLE DATE MONTH/DAYNEAR <br /> yfJl�J J�IR /liaGD �f/N0. � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONCODE OPTIONAL i CENSUSTRACTN -OPTIONAL SUPVISORR--DDISTRICT CODE OPTONAL <br /> 06 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE THIS IS A C NGE OF SITE INFORMATION NLY. <br /> ToaM Allas!I FILE THIS FORM WITH K <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE REGULATIONS <br /> �/ 3-041& <br /> R. 3A V� <br />