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STATE OF CALIFORNIA a`oz <br /> STATE WATER RESOURCES CONTROL BOARD iy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A d� "° <br /> O - I . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �itl, <br /> MARK ONLY ® 1 NEW PERMIT F-1 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q d AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A oO CF-owp, LLC Fkai> PARZAD <br /> ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) <br /> AAGI ' G f}UE D0t4CA4, T <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STockTOO CA gtiSo6 N/.>4 <br /> ✓BOX O CORPORATION O INDIVIDUAL ;9 PARTNERSHIP ED LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'tlowner of USTB a public agency,mmplele#le following:re e of supervisorof division,s ionoroMmwch operates the UST <br /> TYPE OF BUSINESS ;K 1 GAS STATION E= 2 DISTRIBUTOR 0 RESERVATION <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> I� 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS CAC-00 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAST,FIRST) (Z.t= PHONE AREA CODE O DAYS: NAME(LAST.FIR Pp(w PHONE#WITHBREAA C-DE �� <br /> k2Ab FD <br /> -ab <br /> 1A 0-3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE##WITH AREA CODES <br /> AKZAD RGD 48 o3oo <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (RAILINGOR STREET ADDRESS V, bo ndm0 INDIVIDUAL DLOCAL-AGENCY 0STATE-AGENCY <br /> 7 � I GQ CcN I ER ORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE MPCODE 1) <br /> PHONE WITH AREA CODE <br /> STDCI 100 CA 5X0-7 p y7 9 00 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> �i Ce> w�P�rtT'IFS LTu <br /> MAILING OR STREET ADDRESS ✓ bai to noiml9 O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 3 7 L' I �I PT F R, CORPORATION O PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 ocKToi.1 IPA �L� 20 - G17S- 20 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F414-1 D 1010 jalj& <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Fws to indicate ED 1 SELF-INSURED 0 2 GUARANTEE 0 3INSURANCE 0 4 SURETYBOND 0 5 LETTEROFCREDR 0 6 EXEMPTION 0 7 STATE FUND <br /> IJ#STATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles oz I or IlV3;kee <br /> d. tj <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND 91 W NG: I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT ^\ <br /> V, <br /> TANK OWNER'S NAME(PRINTED 851GNATURE) TANK OWNER'S TITLE GATE MONTHiDgY/YEAR <br /> LPCoLo x4enI`S ITD � -o26-a2DD0 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Z[� <br /> m E 7 <br /> LOCATION CODE -OP77ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LPAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORI i THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />