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r • <br /> • <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> PPpp�� COMPLETE THIS FORM FOR EACH FACILITYISITE W o <br /> MARK ONLY JAI 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1:3 T PERMANEN Y D 5 E <br /> ONE ITEM 2 INTERIM PERMIT O d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIUTY NAME NAME OF OPERA <br /> Asko Ac . ID33S �S L� <br /> ADDRESS NEAREST CROSS STREET PARCEL IOPRONALI <br /> 4�55 S-f"H ke F\w S° FPorTCaa� R� <br /> CITY-NAME STATE ZIP CODE SITE P,7'�"E#WITH AREA CODE <br /> Caul�o� CA �2og1gV -aV38 <br /> ✓BOX CORPORATION O MpADUAL [D PARTNERSHIP CD LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY- <br /> TO INDICATE DISTRICTS <br /> NrE'OF[IUSINESS <br /> FOTM <br /> IUSTiapubbryy <br /> cagw , A W Meklawe9 w daupanbor0f CWb .AWb W0K"whEAOParma P#UST <br /> 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(0pt"1) <br /> RESERVATION '1 <br /> 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONk#WITH AREA CODE DAYS: NAME LAST,FIR[) PHONE WITHAREACODE <br /> MCP IA 1jvT ( Lo9\q�8 -a 3i �rcoJ;Ntrc'enaAticm (Soo 2,2- bSA( T <br /> NIGHTS: NAME(LAST,FIRST) RHON #WITH AREA CODE NIGHT5: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 21S�9V� •2y3� �� ,L <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Rszco ?r A" cc) . 6 S <br /> MAILING OR STREETD (, ✓ boaWa # O IMOMOUAL ID LOCAL AGENCY STATE-AGENCY <br /> N^RESS <br /> V . Y UO2.1 CORPORATION I�PARTNERSHIP Q COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAME �"�T' STATE LP CODE PHONE#\+�ITH AREA CODE <br /> C-TtV \ b-)o-NO4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER \\ CARE OF ADDRESS INFOR AT10N <br /> Rcu QT-0" co • &R*e <br /> MAIUNG OR STREET A DRESS ✓ 0m to aMol9 Q WDMDUAL O LOCAL-AGENCY STATE-AGENCY <br /> bc A Q O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STE ZIP CODE PHONE# TH AREA CODE <br /> est � Rb�o2-[903 ����� �D <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 <br /> F--]- Q (j (� 5 0 lD <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓0o[MEtlpls 1 SELF-WSURFD =2 GUARANTEE 0 3 INSURANCE O ETV <br /> 1 SURSOND Q 5 LETTEROFCREDR =6 EXEMPTION O]STATERIND <br /> B STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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 NOTFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANKW1RS NAME(PRIINTED&SIGNATURE) TANK OWNER'S TITLE DATE MpN11T <br /> \ \At ;`\\ tm-j . "�°AV/YEAR <br /> `3 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY N <br /> m ` kit J3 -3D <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS W <br /> F ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGI&DLTSTORAGE TANK REGULATIONS <br /> FORM A(6-95)To- J4N-,ToOyIN CD �1�.� •10,4- 3gT `SIaM-T�UA1 U. 0151o`-W5 S <br />