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0 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA A %—/ COMPLETE THIS FORM FOR EA H FACILITYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE S'`3 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DRAOR FACILITY NAMENAMEOFOPERA PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) NIGHTS: NAME (LAST, FIRST) OR NIGHTS: NAME (LAST, FIRST) PHONE If WITH AREA CODE 9-'/7 CaN m/o CITY NAME- f1ar� Lam ce ADDRESS PHONE # WITH AREA CODE NEARESTCROSS TREET 5 -346 - PARCEL a IOPTONAU vn s 3 CIN NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE 1 D+J CA TOINDIIC TE D CORPORATION D INDIVIDUAL = PARTNERSHIP O LOCAL -AGENCY O COUNTY AGENCY O STATE -AGENCY FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS O T GAS STATION 2 DISTRIBUTOR # OF TANKS T SITE E. P. A. L D. # (optimal) q SERVATION Q 3 FARM O 4 PROCESSOR [= 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional FIR DAYS: NAME (LAST,ST) lawrewc PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME--/�� �{r �fxPN C'E CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS STATE ✓ box la Indicate Q INDIVIDUAL O LOCAL -AGENCY O STATE -AGENCY 9-'/7 ,(}' k CORPORATION D PARTNERSHIP Q COUNTYAGENCY ] FEDERAL -AGENCY CITY NAME- STATE ZIP CODE PHONE # WITH AREA CODE 04 5 -346 - Ill. TANK OWdER INFORMATION - (MUST BE COMPLETED) NAME OF OW R -�' CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS CITY NAME ✓ box b Indicate INDIVIDUAL LOCAL -AGENCY STATE AGENCY 0 CORPORATION D PARTNERSHIP D COUNTY -AGENCY O FEDERAL -AGENCY STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HQ 4 4 - IV S V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED ✓ Wxb indicate 1 SELF-INSURED E GUARANTEE 31NSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # sc.co�vi LOCATIONC PTION , ICENSUSTR OCT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL cJ 00"+r/x 7.16 .3/19/92 c# THIS FORM MUST BE ACCOMPANIED BY. AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.