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i <br /> STATE OF CALIFDRNIA '"•"' `i, <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 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE CLOSE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J <br /> DBAORFACILITYNAME NAME OF OPERATOR <br /> l�C-AL- �IIG� A.-rlp�1 '�llb-1 l <br /> ADDRESS W"creWl,- � IIAREST blA14 STREET vv <br /> CITY41 �• <br /> O <br /> CITY NAME D ` STATE A Z�CODE SITE PHONE%WITH AREA CODE <br /> SNI <br /> ✓ Box <br /> TO INgCATE CORPORATION INDIVIDUAL O PARTNERSHIP LLOCAL-AGENCY ED COUNrY.AGENCY Q STATE AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR I 0 -/ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> �y„ p <br /> 3 FARM 4 PROCESSOR = 5 OTHER RESERVATION <br /> pq TRUST LANDS ./ C^v ,7elb <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) eiO-��— <br /> Lal.L.al (Il�l.�t MP.t2k Zt�T -7(GG??7 S\��K 1Z1CK <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR EA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CnDP <br /> PHONE#WITH AREA Copp <br /> 11�1ct�aA .1t1c� t-ems 7t3- Ut 1Q�w cL�Y�lc( l-8�a-1z3-7� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREET ADDTRREEESSSr ✓box bindkI�ale O INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY <br /> ✓II Wt �j k [ CORPORATION E-1 PARTNERSHIP <br /> O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> �NAME��OF yOW�N�ER^ � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓,,box x"nd N O INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> J`1 �t"'"r^xT�F/ C.�✓��^ CORPORATION PARTNERSHIP 0 COUNiY.AGENCY = FEDERAL-AGENCY <br /> CITYI -0M r� STATE ZIP CODE PHONE%WITH AREA CODE <br /> 1L/-­ '�---c+J li^ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - O O > <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> box pLkkate 0 I SELF INSURED 2 GUARANTEE L-1 3INSURANCE <br /> a SJRETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION [-I 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 NOTIFICATIONS AND BILLING: I.E II. 111. <br /> THIS FORM HAS BEEN COMPLETED UN ENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLI S AME(P�flIINCTEDB SIGNATURE) O APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AG NCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY It <br /> 23 s <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-GjWTRICTTCDE -OPTIONAL <br /> THIS FORM MUST B AC <br /> FORMA(5-91) OMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORW3]A 5 <br />