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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3t: UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Cit i•O�N.� I� COMPLETE THIS FORM FOR EACH FACILrFY/SITE MARK ONLY LICI 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SRE ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DeA OR FACILITY NAME NAME OF OPERATOR ARCO O4Ac'r, C6MP6rS STGY-kTOtJ'TEIU1110 L- �QLFj PILO D�i S CCA n) Y ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 2-fvo WE5T WA-3++jkA-ro0 5 -r -rop-I<- CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE oc,.-rvl.) cA 9520.3 CA 1951423 209 4(v to- o_�f v BOX TO INDICATE DAORPORATION 0 INDIVIDUAL E:l PARTNERSHIP O LOCALAGENCY 0 COUNTY AGENCY O STATE AGENCY (] FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR [Vf'5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) /� /P�HONNEx WITH AREA CODE DAYS: NAME(LAST,FIRST) /� L Z�#y� 146 IL� 11111A� _ HONE �lil e-Y 4 0 41U�11 LQ I fC' L.� n ` ', 1 ''II `IVCn-Ip'Tv NIGHTS: NAME(LAST,FIRST) HON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ^ �� _ / E C I,et'l i� 20 9) 3 q - 4U G'yoLyl P�A � (C 'A CODE H. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NA E CARE OF ADDRESS INFORMATION 1 n Iia o�LAcTs COMPAN• Brad S nce� MAILING OR STREET ADDRESS ✓ tax 0Im"o Q INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY o Box 512-5--To CORPORATION O PARTNERSHIP L-1 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Los A+�c,E�es1 CF} �ID051 - 050 21' 4 -O SL III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION AP-c0 F-t-oTXLcTs COMpgn1 brad S MAILING OR STREET ADDRESS ✓ tax becale enter� = INDIVIDUAL E-1LOCAL [� STATEAGENCY 'p(_7 2*)( 5 12S-v IBJ CORPORATION = PARTNERSHIP E-1 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE Los ANc oL c-5 C( gp1p51 - G5_-0 2-13 4 -0(n 52_. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ L4 41-1() lo la Is I 0 I(o V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa bin0icale 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 6 EXEMPTION BB OTHER 71 VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[54 II.= III.IJ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR bGv. A . e Qrivi ali 1 q� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY III �p (f- Cf 3'9 1--F _ RIC LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR DISTTCODE -OBTIONAL o(^ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A R6