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xso +�ca P STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A aP COMPLETE THIS FORM FOR EACH FACILITYISITE I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T 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 NAME NAME Of OPERATOR ✓aGVH PARCELN(OPTIONAL) ADDRESS NEAREST CPOSS STREET q/�fj �L7d• — CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA COPE La>>� CA f� 367- VS"8 ✓ BOX CORPORATION D INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATEDISTRICTS 'If owner of UST is a public aphCV.olmpleta the foM1In9 nanw d s psNisofof dmhW,seGlon oroNice whidl apBraleslha UST TYPE OF BUSINESS a I GAS STATION ❑ 2 DISTRIBUTOR RESEIRVATION F INDIAN #OF TANKS AT BITE E.P.A I.D.#(optbnaQ ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUSTUSNOS o — o91 3 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P ONTH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Z� EA WI7-�no6 A4�E c� C Z-, 567- NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARFA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 990-�8�/ II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESP INFORMATION NAME ; t/I �r/iTT ✓ box to ndxzte 0 STATE-AGENCY MAILING OR STRE ADDRESS /w .�7 O CORPORATION 0 P ERSNIP I� COUNTY-AGENCY FEDERAL-AGENCY CITY NAME T STATE ZPCCODE PHON ITA ODE Lap/ Z n III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Vie,L�7-7-10,0 ✓ boxtnutdoode MAILING OR STREET DDRESS f� INDIVIDUALO LOCAL-AGENCYQSTATE-AGENCY MAILING OR STRE� �� =CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AG NCY CITY NAME STATE ZIP CODE PHONE#YVI%7 CODE 0 Ga, C4CZv9JJ bb�- IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to micata 1 SELF-INSURED 2 GUARANTEE O 31NSURANCE =4 SURETY BOND D 5 LETTER OF CREDIT O 6 EXEMPTION O T STATEFUND Q 9STATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 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 TANK OWNER'S DATE MONTHIDAV/VEAR AVE TANKOWNER'S TITLE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �.F--- m LOCATION CODE -OPTIONAL CENS`US—TRACT# -OPTIONAL SUPV'ISOR-DISTRICT CODE -OPTIONAL Z7, 5't-JIS[74 I? 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 FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO 11W ORAGE TANK REGULATIONS FOP-0 A(6-95)