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s c C ) !k 10-1�t'Lt SVT RC STATE OF CALIFORNIA IbII3�by ` .• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ro COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE MARK ONLY bbb��'\ ONE ITEM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) � �C D - NAME OF OPERATOR SSSFCrrlYNA.ME M,, CoC' NEAREST CROSB STREET_ PARCELf(OPnONAy _ I) STATE ZIP CCODE �� SITE PHONE k W�� OE C C ��!�J C� . S ✓BOX Q CORPORATION A�_I WIVIDUAL ❑ PARTNERSHIP E:I LOCAL-AGENCY O COUNfY-AGBICY' STATE-AGENCY' ❑FEDERAL-AGBICY' CTS TO INDICATE Tv S 'tlawwdllSTuaD°°°°agefvy,mmpWe N°1°tlmvilgll9l�BdslpMVE°TtlU(CXYI,Sanl]flol°f8m whin opalmes the UST ✓IF INDIAN aOF TANKS AT SITE E.P.A. I.D.k(opfipnal) TYPE OF BUSINESS ra+1 GAB STATON ❑ 2 DISTRIBUTOR RESERVATION /' Ic❑�3 FARM ❑ 0 PROCESSOR ❑ 5 OTHER ORTRUST LANDS (fes (, �O�<-X-. EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) optional PHONE M WITH AREA CODE OAA NAME(LAST.FIRST) PHONE M WITH AREA CODE DAV E(LAST.FIRST) A� SSC �Q PHONEM XAREA CODE Nlr S: NAME(LA(S+L/,f�1RST) PH,yONVE k WITH AREA CODE II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) C,.RE OF ADDRESS INFORMATION NAME bul°idicats ;GR:IADMWAL O LOCAL-AGENCY O STATE-AGENC! MAILING OR EET ADDRESS CI �D C.]CORPORATION C-1 PARTNERSHIP a COUNTY-AGENCY a FEOFAAL-AGENCY ST.LTE IJPCDDE�/�/ - PHONE Y WITH AREA CODE CITY NAME Q /� I 6 (Y' III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION MANNGO TREEf ADDRESS '� box1a ntl�N ❑9DMWAL ❑LOCAL-AGENCY ❑ STATE A O CORPORATION PARTNERSHIP O COUNTY-AGENCY ❑ FEDERAL-AGENCY ,/9 �. STATE ZIP DE PHONEB WITH AAREADCODE _ CITY NAME i' / / /` l l . L L (v0 OO IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-T4--]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bil7raro ❑ 1 SELF-INSURED I� 2 GUARANTEE INSURANCE O A SURETY BOND D 5 LETTER OF CREDIT I1 8 EXEMPTION 0 T STATE FUND O8STATEFUND&CHIEFFlNANCWOFFICERETTFA OBSTATERIND&CERTIFICATE OFDEPOST 010LOCAL GOVT-MECHANISM 09BOTHER 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'q III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUEAND CORRECT TANK WNER' NAME(PRINTEDSSIGNATUR TANKOWNEFISTRLE DATE MO AYNFAR C to S1- I ® T /v 7os LOCAL AGENCY USE ONLY COUNTY p JURISDICTION FACILITY EE UREI CODE - LOCATION CODE -OPTIONAL CENSUS TRACT M -OPTIONAL Sl1PVISOR•DISTRICT OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(8.95)