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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i 4 C��U�NDGROUND STORAGE TANK PERMIT APPLICATION - FORM A v COMPLETE THIS FORM FOR EACH FACIL E MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMT _ ., N EOFOPERATOR ADDRESS e NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE 317E PHONE#WITH AREA CODE 5 L l� Ca v f- Lf /7f 34 TOIN Box O CORPORATION l� INDIVIDUAL l=PARTNERSHIP I�LOCALAGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDEML-AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN 4 PRKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM O OCESSOR Q S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) _r PHONE#WITH AREA CODE r: NAME(LAST,FIRST) Lcc s - `/Y/- NIGHT . N ME(LAST,FIRST) PHONE#WITH AREA CODE IGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE_ II. PROPERTY OWNER IN ORMATION• MUST BE COMPLETED NAME / CARE OF ADDRESS INFORMATION SCt A'K� � H AJ MAILING OR STREET ADDRESS ✓ boxbindka INDIVIDUAL Q LOCAL-AGENCY D STATE-AGENCY l.015- �- CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME 5;4 �� _ _ STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blr&b O INDIVOUAL �.LOCAL-AGENCY Q STATE-AGENCY CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME 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 - j V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bm biMkale 0 I SELF-INSURED I=2 GUARANTEE E::] 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OF CREDIT L�l 6 EXEMPTION W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch ed. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.EeH.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# �FACILITY# P IP I.5 ® �Lu LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT COO OPTIONAL / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE INFO ATION ONLY FORM A("I) _ J FOB A5