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eeA <br /> STATE OF CALIFORNIA ��STATE WATER RESOURCES CONTROL BOARDn'UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A4°�� <br /> COMPLETE THIS FORM FOR CILRYISITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT -__j 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ACI NAME �GG NAME OF OPEflATOR <br /> ITY NAME NEA ST��11� 1EET� / PAflCELIIOPTgNAII <br /> C !N/ STATE <br /> CA C !/� OOR) CODE <br /> 2� <br /> God <br /> TO BOATE D CORPORATION INDIVIDUAL I�PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY D STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS I <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR RESERVATDIAN n OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> [NIGHTS: <br /> AYS: NAME(LAST FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> G�> AF, !�v t - ??230 <br /> NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADDRESS ✓ box blrAkate 0 INDIVIDUAL O LOCAL-AGENCY I�STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP I= COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ! /-- S1jEZIPC D�� - /^ $H q WITH��E�A CODE <br /> ZZ3a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) GLS/ fJ �/ !l !Y�'�/ a L <br /> NAMUO�N RCAPE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlkaze 0 INDIVIDUAL O LOCAL-AGENCY I�STATE-AGENCY <br /> � <br /> _7UO-� ����/(J� S�TARPORATION ZP CORD PARTNERSHIP 0 CO �W.76gOOv Zi /`NCY FEDERAL-AGENCY <br /> CITY NAME r- ��� o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓WXbinEbaW [__1 1 SELF-INSURED 0 2 GUARANTEE 0 3INSURANCE 0 d SURETYBOND <br /> I�5 LETTER OF CREDIT 0 6 EXEMPTION 0 IN 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.E] II.E-I III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIL3# �'e <br /> L- .oma�I�11��JI <br /> LOCATION -OPT/ONAL CENSUS TRACTN -OPTIONAL SUPVISOR�ISTRICT CODE -OPTIOPTIONAL <br /> O //Of <br /> THIS CORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. G <br /> NN. FF <br /> FORORRM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOI <br />