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.3-- es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3•�•, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W '4 <br /> CSI i.UM M' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> � 1 NEW PERMIT F7 3 RENE <br /> MARK ONLY WAL PERMIT ® 5 CHANGE OF INFORMATION J 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Aaco �Ac,\� " S4b°► tit)►�H-c tiNTeQ ,zee <br /> ADDRESS NEARES�j CROSS STREET P CEL#(OPTIONAL) <br /> X30 so • l�ll��Suty UI�A ,�111J S 1N6TON <br /> CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> CA LOS <br /> (tiog y - bb33 <br /> ✓ BOX <br /> TO INDICATE DISTRICTS CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS X GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> RESERVATION <br /> 77 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONES WI'H AREA CODE DAYS: NAM (LAST,FIRST) (2o5�a�b -bL 33 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) 9 <br /> %%NNGM on %e4\' 33 Acto 1nNjt4fe~Ca PHONE#WG. <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> kS � \\tCb UCAS cc) , E%kv S <br /> MAILING OR STREET ADDRESS ✓ box bIndicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ,?.o - ba 602s CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY f=1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x TH AREA CODE <br /> AR-Ces CA %no---b03$ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNS CARE OF ADDRESS INFORMATION <br /> Rao 6kUc-\1 Co - I:W{ S <br /> MAILING OR STET ADDRESS ` ✓ box ID indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> T b . pO3� ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL•AGENCY <br /> CITY NAME (� STATE ZIP CODE PHONE#.KITH AREA CODE <br /> tl(Z. e.s%a IZOI,, I �i0702-(0034 (1 t 6-70- <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 !,- O C3 1 o IQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo:b indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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.❑ it.a 11I.V, 71 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTWS TITLE DATE M NTAYNFAR <br /> �arc��'(\ . i__ 20 °►�O <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL !CENSUS TRACT x -OPTIONAL I SUPVISOR-DISTRICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) \ \ ,\ G_• ` <br /> FOR0033A-5 <br /> -TO,, 50.N �aaq�\N CO • �lio\\� F�IZPI� y�v�/. eA l���v <br /> 7-6 . 60x 2orA <br />