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wta°ua < <br /> STATE OF CALIFORNIA ° <br /> s <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 /NEW PERMIT E:] 3 RENEWAL PERMIT % 5 CHANGE OF INFORMATION 7 PERMANE OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE b <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITVNAIONt)9` NAM�V�RATOR <br /> ADDRESS <br /> O� J w�- NEAREST CROSS STREET PMCELI(OPTIONAU <br /> CITY NAME S STATE ZIP CODESITE PHONE%WITH AREACODE <br /> ra CA s3')b 209- 835- ?900 <br /> TOI/ Box <br /> INDC TE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN Y OF TANKS AT SITE E.P.A. I.D.0 Wicnal) <br /> X>A RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 CA"000 x9 6-1 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonel <br /> DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) ad q g-7 s- 7900 <br /> W-2SerJ T,«. 0209 — 835— 900 uJ Toe rF#WITH AREA CODE <br /> NIGHTS: NAME( .FIRST) PHONE»WITH AREA CODE NI/G�HTS: NA (L.A�ST.FIRST) X9 - 836 - OSOS <br /> 2SQt A V� - 1 &-Aw U-0 e- PHONE v WITH AREA CODE <br /> ROPER Y OWNER INFORMATION• MUST BE COMPLETED <br /> F.AA_1LTING­.CR <br /> ME*FWNER <br /> oAEOF ADDRESS INFORMATION <br /> AMA <br /> REET ADDRESG J LlV �xm���M I� INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY <br /> aoxQ. CORPORATION � PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AOENCY <br /> TATEZIP CODE PHONE t WITH AREA CODE <br /> ot.� GIFScoBER INFORMATION-(MUST BECO PLER 1 1A /' CARE OF ADDRESS INFORMATION <br /> oll (ASA rs .mac. (oREET RESS ✓ Dox bintlkale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> - CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> I - STATE ZIP CODESt O N WITH�AREA ZCO �O O <br /> CA <br /> NM OARD OF EQUALIZATION UST STORAGE F OUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) H 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkM I SELF-INSURED (]2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTEROFCREDrr D 6 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owne s bo I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE U N <br /> OR LEGAL NOTIFICATIONS AND BILLING: ba I <br /> 11.O III. <br /> THIS FORM HAS BEEN CO UNDER EN OF RY,AND TO THE BEST OF MY KNOWLEDGE, RUE D CORRECT <br /> APPLICANT'SNAME(PRINTED&SIGNA URE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> DAN10 �' fie( �� A55�. IZ- f7- TZ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# #ISDICTION p FACILITY u lq w <br /> aevp/ 0 s <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SU ISOR-DISTRICT CODE -OPTIONAL <br /> 0 � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO LY. <br /> FORM A(5-91) SA-5 <br />