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• 80VM STATE OF CALIFORNIA • ^e e• ei STATE WATER RESOURCES CONTROL BOARD 3«� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e o Ole, COMPLETE THIS FORM FOR EACH ACILITYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAFACILITY NAME NAME OF OPERATOR�G�I� ADDRESS x#' NEAREST`CROSS STREET PARCEL#(OPTIONAL) /el'yd/ e'�� q Cf/GY�OB�/AGYs� CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE BOX /JD CA ZLZ) TO INDICATE D CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY STATE AGENCY D FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.If(optional) RESERVATION ❑ 3 FARM 4 PROCESSOR 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) G Gi L N 4 3G�-� 1 PHONE 9 WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COD II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MG OR STREET ADDRESS /x ✓ box bintlbala INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY AILI ✓P vx IOb D CORPORATION E::] PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE GvV2 G4 Z<'2W III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G-.E� c��,�rNS �,�v iic✓ MAILING OR STREET ADDRESS ✓box toMate = INDIVIDUAL D LOCAL AGENCY O STATE-AGENCY P /34)x- 16o OCORPORATION O PPAR'TNNEERSHIP /COODUNTYAG4TEENCYY OFEDERAL-AGENCY CI BGd�-TATEZIP CO��'l l G NY NAME O�iJ 7�H AREA C,ODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 - GjZ Z z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b INIcate I SELF INSURED Ejj 2 GUARANTEE E::] 3 INSURANCE O d SURETY BONG (] 5 LETTEROFCREDIT =6 EXEMPTION O 93 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: 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 T ITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 6-4 elv'I,T// LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL FT 33 y� z3• 3Zo THI FORM MUST BE ACCOMPANIED BY AT ST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A5