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r • a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE S I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR GST DF Loot �• �-^ ADDRESS NEAREST CROSS STREET PARCEU(OPfgNAM CITY NAME STATE ZIP�CODE' •'� SITE PHONE i WITH AREA CODE 7,0,0-7- CA Z-' 333 6�0 TO.1 BOX INDICATE CORPORATION O INDIVIDUAL 0 PARTNERSHIP �06ALAG�SE•NCY 0 COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' •R inner of UST Is a public agency,complete the following:nave of Supervisor of dNkbn.section,or office which operates the UST TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR D R.1EgyNDIAN A OF TANKS AT SITE E.P.A. I.D.0(optional) TION 3 FARM Q 4 PROCESSOR Y5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION G/7' d Goffs• MAILING OR STREETADDRESS ✓6D6 bh5cAe O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY v. i3o 06 O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE Zoo-rIM-4 1 �75Z�Z� a 'a i 6706 III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Gid Of 44ams MAILING OR STREET ADDRESS //' ✓ box bindbas INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY /0• OOp ED CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONEA WITH AREA CODE l.0 9$'Zyp +xT 333-670 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 bintlbeM D t SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND O 5 LETTER OF CREDIT 0 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.[—] U. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �� F Fq-c)T6Tr5 I Q I2/7 97 LOCATION CODE -OPTIONAL CENSUS TRACTA -OPTIONAL 9UWISOR•DISTRK:T CODE -OPTIONAL 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FOR007AA7 • a-loA1