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03/31/1999 11: 36 7146705d?-O EHS ARCO LA PALMA PAGE 02 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL HOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITYMTE °• ,.a ,. <br /> MARK ONLY 9 NEW PERMIT ® 3 RENEWAL PERMIT 5 CHANQE OF INFORMATION CD 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q Z INTERIM PERMIT ® 4 AMENDED PERMIT ® e TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION.&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> �CvC 19020 R 1� <br /> ADORC-SS NEAREST CROSS STREET PARCEL 1(OPTIONAL) <br /> CITY NAME STATFZIP ODE SITE PHO M WITH AREA CODE <br /> CA CI-t <br /> ✓Box ®CORPOAATION trINDMDUAL 0 PARTNERSHIP ®LOCAL-AGENCY a COUNTY.AdENCY- ® STATE-AGENCYC�j PEE9AL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> A ownerol UST is o P&Ic anew/,OW916,thr jDr4winT.n4mo d S11P41Y1[or d di✓iei0n,SWIon or Olks whid1000111146 IN UST <br /> TVP[OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR RESERVATION INDIAN I OF TANKS AT SITE E,P.A, I.D.I(opu0 <br /> ona <br /> RESERR VATION <br /> 3 FARM 4 PROCESSOR ED a OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-0010nal <br /> DAYS: NAME(LASVFIR T�, P ONE WITH AREA COD DAYS: NAME ST,FIRST) RH NE Y WITH AREA CODE <br /> C rYT - �GQ. GN' ® �24 2'S.1, <br /> NIGHTS: NAME9 FIRST) PH E LTH AREACODE NIGHTS: NA E(LAST.FIR Tl PHONE 0 WITH AREA CODE <br /> 2113 An\S _ C�rrxl 2,z- L3'A <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CCG !`O (_0v S <br /> MAILING OR STREET ADDRESS ✓ box b 002314 0 INDIVIDUAL [j LOCAL•AOENCY Q STATE-AGFNCY <br /> p� 2 RPORATION0 PARTNERSHIP © COUNTY-AGENCY CJ FEDERAL-AGENCY <br /> CITY NAME lJ J STA E ZIP CODE PHONE r TM AREA CODE <br /> 042= 01 <br /> 13$ <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDAESS ✓ Dox toMldla INDIVIDUAL © LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION ©PARTNERSHIP M COUWY•AGENCY Q FEDEPAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE;I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE=ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4_14]_ <br /> - <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Gas to fndlralm <br /> 1 SELF-NSURED fD 2 GUARANTEE CJ 3 INSURANCE (_] 4 SURETY BOND Q S LEITEROFCAED(T 11 0 EXEMPnON ::Eo��,-IUND0 g.STATe;FUND4CHIEFFINANCIALOFFICERLF.TTHR ®'9 STATIE FUND B CEPY1FiCATE OF DEPOSIT ® 10 LOCAL GOt/T,VAECHAN151A Vi, LEGAL NOTI <br /> FICATION AND 13ILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or(Iis checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD 0E USED FOR LEGAL NOTIFICATIONS,AND BILLING: P• <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK O 5 NAME(PRINTi<D 6 SIGNATURE) TANK OWNER'S TITLE \ \ DAT!_ MONTH/DAY(YEAR <br /> �� yr <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JU ISOICTION N 1'ACIUTY Y <br /> LOCATION CODE --OPTIONAL CENSUS TRACT 0 CF00NAL SUPVISOR•DISTRICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 9,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER.MUST FlLI~THIS FOR►''-"TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI IND STORAGE TANK REGULATIONS <br /> FORM A(6.93) <br />