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�I. pegOURC.S C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a = UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A O�(IFGN N,♦ 4!�7_ COMPLETE THIS FORM FOR EA FACILITY/SITE MARK ONLY F-] 1 NEW PERMIT F_� 3 RENEWAL PERMIT Tf 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE :!Y-3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Gcs r� Girl P. p J« _ ADDRESS NEAR ES CROSS STREET PARCEL#(OPTIONAL) 30O 3 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE v ccs CA 336 d -23q ✓ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS �j 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 1c 3 FARM 0 4 PROCESSOR Q 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) = d41f I c c,+� sktj ld?-237 — 215PHONE NIGHTS: NAME(LAST,FIRST) f PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING O STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 1A 00 S W Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Ma-.4-ccL C' ` 53"3 6 z 0?-23 Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SG'm-e 0S :% MAILING OR STREET ADDRESS ✓ box to Indicate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 F4-T-4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box b indicate Q 1 SELF-INSURED ,Q,�GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Ly 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i5 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# It71"Y`# ® I I I I 3 GASP��3 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT NAL SUPVISOR-DISTRICT CODE -OPTIONAL - 2-z-- �.. z 9� /Q THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. t FORM A(5-91) I FOR0033A-5