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STATE OF CALIFORNIA y •``o�p.: �i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w _; Ow COMPLETE THIS FORM FOR EACH EACILITYISITE _-"-- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR rc4 Srnai 1 ix A, ADDRESS NEAREST CROSS STREET PARCEL#(OPTgNaU S, p/�� u P CITY NAME y 3</s., STATE ZIP CODE I SITE PHONE#WITH AREA CODE 0"7 CA aro G ✓ Box TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY DISTRICTS OSTATE-AGENCY FEDERAL-AGENCY TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE❑ P.A. I.D.#(optional)3 FARM O 4 PROCESSOR O RESERVATION ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) >Ct vAtP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Eos biMNN4 Q INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY CORPORATION E= PARTNERSHIP =COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE+WITH ARE-CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGORSTREETADDRESS ✓Dox biNiW4 Q INDIVIDUAL Q LOCAL AGENCV O STATE-AGENCY CITY NAME CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY STATE ZIP COOS PHONE#WITH AREA CODE IV. ARD OF EQUALIZATION UST STORAGE FEE A UNT NUMBER-Call(916)323-9555 if questions arise. Y(TK) HQ F474 - 3 a (P V. TROLEUMLISTFINANCIALRESPONSIBILITY-(MU ECOI ETED)—IDENTIFYTHE METHOD(S) USED ✓boa biM AA O I SELFINSURED O UARANTEE 1�9 1 URANCE OFCREDIT 6 E%EMPTION D d SURETY BONG OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTEDB SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUSTRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL S THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FO FORM A(5.91) RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR007iA5 0 �