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I <br /> 1' <br /> 0 <br /> STATE OF CALIFORNIA s` ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A . a <br /> C�AIIOnM'� � <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> © f NEW PERMIT 3 RENEWAL <br /> PER q5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> zzz <br /> MARK ONLY 4 AMENDED PERMIT �0 6 TEMPORARY SITE CLOSURE <br /> ONE REM 2 INTERIM PERMIT D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR �l <br /> F. IPA OR FACILITY NAME �p�.c�T <br /> -Dklut ,s/cclrlG/IJ T�i7/�)lLC/� �/AnI S NE EST CROSS STREET PMCELFIOPfI0NA4 �/ <br /> ADDRESS �S�-20.5 - <br /> 1200 E . rdE<9t.� AYE. STATE ZIP CODE SITE PHONE#WITH AREA LADE <br /> CITY NAME 2 0 9 'Z/6✓��7 y� <br /> STocK7_C cA �52oS CA <br /> ✓ DX <br /> LOCAL-AGENCY (l COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO IN tCATE O COfiPORATN)N ®INDIVIDUAL Q PARTNERSHIP O DISTRICTS' <br /> • ates the UST <br /> N comer of UST is a public agency,mwlete the following:nava of Supe,isor of c h,16 sectbn,or office whb�operIF IND1AN #OF TANKS AT SITE E.P.A. I.D.#(aplAxMl1 <br /> TYPE OF BUSINESS IGAS STATION Q 2DISTRIBUTOR RESERVATION / <br /> 0 3 FARM 4 PROCESSOR ® 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> �00wj �RE, <br /> NE#WITH AREA CODE <br /> 14 <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST / <br /> L U)ICCNCL 20y47'l fi Cc. i10 A/J�A'Ew GCOOED- - ONE#WITH AREACODE NIGH TS: NAM,E/(IAST,FIRST) � / <br /> NIGHTS:.NAME(LAST.FIRST) �r-'GL �-( 2cii l,j �S2� �C7 �� 9✓'/� /5 0Y <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> PMAMILING <br /> ,c�crtbWblMicabINDIVIDUAL LOCAL-AGENCY QSTATE-AGENCY <br /> OR STREET ADDRESS <br /> / �'/ :� �j�^ Q CORPORATION 0 PMTNFASHIP COUMYAGENCY -1FEDERAL-AGENCY <br /> _7 STATE. IPCODEPHONE#WITH AREA CODE <br /> —/ I CITY NAME C/�1 9.'7 o-7 <br /> F%Omi <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> t / r ✓ boa biMicak INDIVIDUAL LOCA4AGENCV E:] STATE-AGENCY <br /> MAILING OR STREET ADDRESS I� <br /> ay �,aii✓f�fo[J U�� O CORPORATION O PARTNERSHIP Ij COUNTY AGENCY (] FEDERAL STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME (JA ✓;�07 -''� <br /> K'TC NI _ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 3 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Q I SELF INSURED O 2 GUARANTEE E7 3 INSURANCE O4 SURETY BOND <br /> .1bMbinEbale 5 LETTEROFCREDIT ED 6 EXEMPTION [_1 go OTHER <br /> II <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.F] I.= 111.0 <br /> THISFORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TE MONTWDAY/YEAR <br /> OWNER'S NAME(PRINTED&SIGNEDI <br /> OWNER'S TRLE DA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 <br /> LOCATONCODE -OPTIONAL CENSUS TRACT# _O TIONA SUPVISOR-DISTRICT CODE - TJOs:NAL <br /> 1/7)0(0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORW33AA7 <br /> FORM A(393) � <br />