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l STATE OF CAUFORMA ( c�= <br /> STATE WATER RESOURCES CONTROL BOARD s® r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA FAt7LI 1SITE <br /> MARK ONLY u t NEW PSRMIT 7 3 ;;ENEWAL PERMIT r7i S CHANGE OF R*ORMATWN 7 PERMANENTLY COO SITE <br /> ONE ITEM Ei 2 INTERIM PERMIT a AMENDED PERMIT C] a TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ll lZ9 <br /> OBA OR FACtUTY N E NAME OF OPERATOR �j u t <br /> ADDRESS I NEAREST CROSS STREET PAACELt)OPTIONW <br /> CITY NAME STAG IIRH P CODE L I SITE PHONE s WAREA C:DE <br /> 5 P <br /> ✓ 3ox CORPOgAnoN Q IMMM AL Q PMTNEp" •S W Q cDulmrr AGENCY Q srATE• r C RDERAL AG^e ICY <br /> TO INQICATE <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORRE RVATION C-1NOIAJN A OF TANKS AT SITE a P.A. L O.s(Goomw) <br /> 3 FARM Q a PROCESSOR r-1 S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s.WITH AREA CODE DAYS:NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE$WITH AREA CODE Nx3HTS:NAME(LAST.FIRST) <br /> NO a WTrW A05AR05 CCCO <br /> li. PROPERTY OWNER INFORMATION•(MUST BE COMPLE-70 <br /> NAME -42CARE OF ADDRESS INFORMATION <br /> GSC t � 11 / <br /> NAI ING OR STREET ADDRESS x�°x = IOCAL•AGENCY j_5TATE•AG81CY <br /> Z. S 1 �'r!✓ ✓ I CORPORATION Q PAMWURSHPQ COUNY-AGStCY I_ -mEm4mcy <br /> CITY NAME STATE STA�� ( Y3P CSE 5 � 67 � PNCNE�VVITH AREA C;� <br /> 4, r �� 7 <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .VAILINGORSTREET ADDRESS ( ✓ xxaumm C:IIgNnOALi=WM4Z34CY (-= STATE4 <br /> 1�CORPORATION r-7 PMTW <br /> MP Cf COUNT`I AGe7VCY FIDERAL AGENCY <br /> CITY NAME I STATE I ZIP CODE I PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-4555 if questions arise. <br /> TY(TK) HO =41-Q 17-1 L4 I=1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J Sox a ts:t se.""m GUARANTEE =1 QLmmmicE = I SIREfY BONG <br /> Q S LErmOFcmrr 6 saaff10N =, W OTWO _j <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and biifing will be sent to the tank owner unless box I or I is checked. <br /> � <br /> CHECK ONE BOX INDICATING WHIG ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS Atm eIU.INQ L I� tL LI in. � <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY XNOWLEDGF—IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED s SIGNATURE) APPLICANT'S TITLE DATE ,yONTWpAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* XRISOCT)CN x 1 AC7LITY$ 6 0 K 141 ! 3" <br /> L? 711 �o'�ii► 98 <br /> LOCATION CODE -OPT70NAL f CENSUS TRACT s -OPTIONAL (C/\} I SUPVISOR-DISTRICT CODE -OPTIONAL ,J <br /> THIS FORM MUST SE ACCOMPANIED SY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> ARM A(5-91) <br />