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0 • a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMEJ / NAME OF OPERATOR ��J 7-L Gt�g�� ADDRESS NEAREST CROSSS,STREET PARCEL#(OPTIONAL) CRY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE GDo_L CA `�5Z ✓BOX O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY" 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS Hower of UST is e publE agency,wmpeoe the lolbwhg name d upermorol dwision,section or office whidi operates 0e UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(oplionall RESERVATION Q ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional OAVS: NAMME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE /3F�lTL w. aU- bio 9)s6 P— 0-7 NIGHTS: ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME ) CARE OF ADDRESS INFORMATION 17_7 MAILING OR STREET ADDRESS ✓ box to kkate 0INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY ej>/ 92. S7— 0 CORPORATION ID PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAM�EQ ST ZIP CODSEz� PHONE#WITH AREA CODE G ) � III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEE,OOF.O-W ER / CARE OF ADDRESS INFORMATION !� T Gfiiv i �•Y/L�r/ MAILING OR STREET ADDRESS ✓ boxto odots O INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY T—CI-7O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bid'ceN D 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDR 0 6 EXEMPTION 0 7 STATEFUND 08 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O10 LOCAL GOVT.MECHANISM O 99 OTHEP 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: 1.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVIZR-DISTRICT CODE -OPTIONAL N, 3 THIS FORM MUST OWNER MUST FILE THIS FORIW(THE LOCAL AGENCY IMPLEMENTING THE U DERGROUI1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IWINFORMATION ONLY. ORAGE TANK REGULATIONS FORMA(6.85)