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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDy cG'� <br /> G UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A " =e <br /> COMPLETE THIS FORM FOR EAW FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 78 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA RFACILITY NAME :l A' 93 NAMEOF,OP �OR <br /> A DR SS5 N. NEART ROSS STRE SPARCEL AIOPTpIUU Cerr�Y <br /> CITY NA IAE STATE <br /> ZIP Ct4� TE PHONE#WITH AREA CODE <br /> /J(�f� 9 - 838 <br /> ✓ Box <br /> TOINOCATE PoRATION Q INDIVIDUAL t1 PARTNERSHIP LOCAL-AGENCY O COUNTYAGENCY Q TE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR D R SERVATT%N #OF KS AT SITE E.P.0. L D.#(aptWnall <br /> Q 3 FARM O 4 PROCESSOR Q 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) <br /> NIGHTS:NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM �/ CARE OF ADDRESS INFORMATION <br /> d6co_ // olevet ro <br /> MAILIWG OR STREET ADDRESS,,//& <br /> DDRESS / binEWM M INDIVIDUALQ LOCAL AGENCY 0 STATEAGENCY <br /> CORPORATION I] PARTNERSHIP COUNTYAOENCY 0 FEDERALAGENCY <br /> CITY ME• �J Q. STAT, OODE &ql/ 17�147I14D� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓DOA bi dic" [1:1 INDIVIDUAL QLOCALAGENCY C3STATE AGENCY <br /> CORPORATION [1:1 PARTNERSHIP E]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) HQ F4—T4-1- <br /> V. <br /> F7 PETROLEU <br /> 4 -V. PETROLEUM UST FINANC L RESPONSIBILITY•(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓tw bMaea# i SELF-INSURED [=1 2 GUARANTEE (] 3 INSURANCE 1 SURETY BOND <br /> O 5 LETTEROFCREDrT O I EXEMPTION Q 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' checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.k III.❑ <br /> THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a Pm JURISDICTION# FACILITY a <br /> CT ARCO ZD OZL l o ti3 ql <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> F/ 23-90 2 <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) <br /> FOTIOI]tA5 <br />