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ASQUR •S C <br /> STATE OF CALIFORNIA kP' Gaa <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORia! A <br /> f! <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE: OF INFORMATION 7 PERMANENTLY CI nc�Kn c�LT� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (/ <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFACILI NAME l NAMEOFOPERATOR <br /> jelmI <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 10351 r_ rh STATE ZIP CODE SITE PHO #WITH AREA CODE <br /> CITY NAME w CA <br /> TI/ BOXND TE 0 CORPORATION ] INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY QCOUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 11,OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 0 RESERVATION <br /> 3 FARM [=] 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMAEAREA <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WIDE YS: NAM ILAST.FIRS <br /> NIGHT NAME(LAST, RST) PHO4 #WITH AREA CODE NI HTS: NAMEr(LAST,FIR } I �y <br /> I V �1 f15, +-- <br /> II. PROPERTY NER INFORMA ION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION �J <br /> '�YIa � Y1- 71 mFgAn ,�;ta <br /> MAILING OR STRE T ADD�SS ✓ bax ro Ind tale 0 INDIVIDUAL 0 LOCAL-AGENCY � STATE-AGENCY <br /> - CORPORATION ® PARTNERSHIP � COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> ��J CITY NAME ^ !� - {f STATE n ZIP�QD PHONE 11 WITH AREA CODE <br /> 15 e <br /> III. TANK OWNER INFORMATION-(MUST BE MPLETED) � �i <br /> NAME OF OWNER 7NICARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> 77 <br /> dox to indicate [� INDIVIDUAL © LOCAL�AGENCY STATE-AGENCY <br /> �CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EE ACCOUN UMBER-Call(916)323-9555 if questions arise. <br /> (TK) HQ [4X- <br /> ,-I d� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F✓ box to ind ccate <br /> [� t SELF-INSURED [:]2 GUARANTEE i� 3 INSURANCE [] 4 SURETY BOND <br /> D 5 LETTER OF CREDIT fi EXEMPTION 099 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.� II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,16 TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONT4 UDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR0333A-5 <br /> FORM A(5-91) <br /> 0 <br />