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0 • ♦ee°oa es co STATE OF CALIFORNIA .° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ro> . COMPLETE THIS FORM FOR EACH F YISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTJ�Y-OCO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM NAME OF PERATOR I \ . 4't �c p/) e') CrvICS SSL.an STT �/I ADDRESS NEAREST CROSS STREET PAHCELN(OPt"NAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE © CA I q530 TOIN ICABox O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 DS RICTSENCY COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY / IF INDIAN I TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ q SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) Lanq s o•. , 016r- 85S'-zy U NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME 1 CARE OF ADDRESS INFORMATION MAIUNGORSTR&fiT DDRESS ✓box 0Indicate = INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME STATTS� ZIP CODE PHONE#WITH AREA CODE Lc� `nrD C '4 L) III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S9M�- MAILINGORSTREETADDRESS ✓ box 0lndkate O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION PARTNERSHIP COUNTYAGENCY 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 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box a Indicate 0 I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE D 4 SURETY POND O 5 LETTER OF CREDIT =6 EXEMPTION 0 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 the ed. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUN # JURISDICTION# FACILITY# (AHG-5 /5 � Em v - LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL © O —,f —f,7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. FOR 0337A- FORM A(5-91)