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`6pUR STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD F r 0 a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F—] 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE ONE REM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR G/7'�_o Goe s �v A ADDRESS /,, NEAREST CROSS ST EET PARCEL 0(OPTIONAL) j 3 S . /,A,t, Lit _: CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Lo%h-- CA G7�?�D 33y-5 ✓ Box TOINDICATE CORPORATION Q INDIVIDUAL = PARTNERSHIP FVr LOCAL-AGENCY000UNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' DSTRICTS' tl owner of Um ST Is a public agency,complete the following:nae of Supervisor of division,Lion,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) flESERVATION 0 3 FARM 4 PROCESSOR A5 OTHER ORI LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,f IRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE inLAl NIGHTS: NAME(LAST,FIRST) P14ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADD SS ✓ box b Indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY J 5/' S- A"A P'INIE D CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE r- lf:� SSP o Z�i� 33 1—_-g6 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G/ MAILING OR STREET ADORE %/ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY / !T/, 1711 S T =CORPORATION E=1 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATY ZIP CODE PHONE#WITH AREA CODE G06_z:_ d j 33el- IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4]-4-]-1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION = 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ if.[::] 111. 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# i Jul LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPV OR-DISTRICT CODE •GWT70NAL oZ Z3. 1 3 � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM FORM A(3193) FOR0033A-R7