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STATE OF CALIFORNIA r o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;° o �4rtpe N`N COMPLETE THIS FORM FOR EACH FACILrTYISITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 9 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE 5� I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAOR FACILITY NAME NAME OF O ERATOR e CGVGI r e%/ 'e2" ADDRESS IE NEAREST CROSS STREET PARCEL 0(OPTIONAL) ? S t) CITY NAME STATE ZIP CODE SITE PHONE#WrJAREA CODE ( o^ Ca , T NDIICCATE r O CORPORATION Z 9 IVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY Q STATE AGENCY FEDERAL TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR [ RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#Fopfional) 3 FARM O d PROCESSOR 5 OTHER OR TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE IF NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LM IT 1-111ST) PHONEI II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxbindicaN 0 INDIVIDUAL Ij LOCAL AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP 0 COUNTY AGENCY O FEDERAL-AGENCY CITY NAME 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 bintlkate I= INDIVIDUAL LOCAL-AGENCY L�] STATE-AGENCY CORPORATION 0 PARTNERSHIP 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) HO 14t4_1-nL V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bWicale 7 1 SELF INSURED E::] 2 GUARANTEE 3 INSURANCE d SURETY BONG _-1 5 LETTER OF CREDIT D 6 EXEMPTION O 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 checked. 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 APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHMAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# W£-�61C 77 LOCATION CODE OPTIONAL� ( J _ AL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL dS 'zC� 3_3D-c/3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. FORM Ant 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • � FOfl0037AR6