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NNW, <br /> � eon" e <br /> t. <br /> STATE OF CALIFORNIA � ' 'o <br /> STATE WATER RESOURCES CONTROL BOARD w...�! _ . 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ,,,� o <br /> CO PLETETHIS FORM FOR EACH FACILITY/SITE <br /> GI 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETIEDEOF OPERATOR <br /> OBAOR FACILITY NAME �� <br /> D <br /> NEAREST ROSS STREET. PMCELAIOPrgNAL) <br /> ADDRESS <br /> STATE 21P COO�E /�/� SITE ONE.WITH AR}EA('CJ9DE <br /> CITY N ME CA �'lnZ% `- / F/V� <br /> Gf/D J <br /> ✓ WX CORPORATION O INDIVIDUAL �PARTNERSHIP (]LOCAL-AGENCYO COUNTY-AGENCY = STATE-AGENCY [-IFEDEMLAGENCY <br /> TOINDICATE DISTRICTS <br /> �-�/ ✓ IF INDIAN .OF TANKS AT SITE E.P.A. I.D..(apfwiwll <br /> TYPE OF BUSINESS L.Q I GAS STATION O 2 DISTRIBUTOR [�:] RESERVATION <br /> O 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PPHONE,WITH ARPACODE <br /> N777T777777=� <br /> Y) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D�A,(YYS':[�/NiAME(LAST.FIRST) PHO /� �17�" ZNIGHTS: NAME(L T,FIRST) oONE.WI IJfREODF , GH : NA��T,FIRST) �p� (,�y/meg <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED CARE OF ADDRESS INFORMA'TIO <br /> :NA00 L' W Wic a I] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> TRE ORESSX 6OCORPORATION I� PARTNERSHIP I�COUNTY-AGENCY FEDERAL#GENCV STAT ZIP CODE HONE.WITH AREA E <br /> S -I-Z-60'Z-;7' /o y07 b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> -a-z'13 M45D <br /> MAILII G OR STREET ADDRESS ,,// ✓ w m4ate E-1INDIVIDUALO LOCAL-AGENCY (]STATE AGENCY <br /> SAO- ��/ �y5 2�[ CORPORATION = PARTNERSHIP I�COUNTY-AGENCY0 FEDERALAGENCY <br /> CITY NAME o V— �•Z— STAT ZIP CODE HONE i W TH AREA CODE <br /> 7D.Z603$, 10 a Zd <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14 47-FDS O D D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Dov minEcale I SELF INSURED ] 2 GUARANTEE I] 3 INSURANCE t]4 SURETY BOND <br /> 5 LETTEROFCREDIT I]6 EXEMPTION W 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.O it. 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) APPLICANTS TITLE DATE MONTWDAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a <br /> 3C7 L - o4D T <br /> LOGATIONCODEOPTIONAL CENSUS TRA T. -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ZD I —�J✓l` L• r ' <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(12.61) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM33A R6 <br />