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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >f , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMES'f l?v J G f NAME OF OPERATOR G� r oFGOJ/ !ct i3tj c>E•�% �� /'- ADDRE S NEAREST CROSS STREET •PARCEL#(OPTIONAL) =33 c leOL CITY NAMEz D STACA✓ -7-ZIP COL L SITEPHONET AREA 67-1-D ✓ BOX CORPORATION E:1INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY COUNTY-AGENCY a STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS ?�/p / M owner of UST is a public agency,complete the folIown¢rare of supervisor of division,sedion or office which operates the U (ST �/�//� `• C7 4� G�� TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR RESbl EIRVADIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR W!�_5 OTHER OR TRUST LANDS v/ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE .J l0 33j NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE GOA111PLFTFp) NAME S l /eal c£ CARE OF ADDRESS INFORMATION C r LO / „liC � �;4 L c fiv TF 11. MAILING STREET ADDRESS ✓ bcx to r_'. 'a = IN'C:VIDUAL O LOCAL-AGENCY (] STATE-AGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE z_D/ / G/f• C� �� 205 7'9 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER SF',2JIc CARE OF ADDRESS INFORMATION 61 i � top/ cr-v i t MAILINGAR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL (] LOCAL-AGENCY (] STATE-AGENCY /7 C /�� CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE O c/V 2 o C 6 7 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4—F4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND 0 5 LETTER OF CREorr = 6 EXEMPTION =7 STATE FUND 6 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND b CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.[�j III. THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE f-.9^0 4el/�l{)G DATE MONTHiDAY/YEAR ��T!� .,1 4s. G ,ec i ) . � � £-✓moi-�� - - � LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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(6-95) J.3