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v a STATE OF CAIIiOHLNSTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O 3 NEW PERMIT F-1 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE p I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR AGl GJG �� ADDRESS NEAREST CROSS STREET PARCELS(OPTIONAL) 300E . El lGE !QL►q CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE 5r1vr*_0 2Ci CA Zo T DCTE laPuD RPO, oTryINDIVIDUAL =PARTNERSHIDISTRICTS' 'V O OUNCY• M STATE-AGENCY' O FEDERILAGENCY' b9aomwrd UST enOe4the IOIIowMa:nerre d Supervbor d division,aelbn, w dlia which apwatec the UST TYPE OF BUSINESS 0 3 GAS STATION [] 2 DISTRIBUTORQ RE RIFF INNDIIAAN s OF TANKS AT SITE E.P.A I.D.#Tep0map Q 3 FARM 0 6 PROCESSOR 6 OTHER ORTRUSTLANCS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAS FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE Ion �ZJ_777 NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CAR OF ADDRIfSS INFORMATION rA E f MAILING OR STREET ADOR SS •fl•l�)< JrG� bDr binlNaN = INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY OZ7 POMnON O PARTNERSHIP O COUNTY#GENCY O FEDERALAWNCY CITY NAME 8TA ZIP CODE PHONE#WITH AREA CODE PWIJ 16VO)TIS - 5"C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION /F/G iT MAILING OR STREET ADDRESS ✓ MONgbW INOIVDUAL 0 LOCAL-AGFNCY D STATE AGENCY 717• / 8 COIIPOfUnON I= PARTNERSHIP L3 COUNTY#GENCY O FFDEML#GENCY CITY NAME TATE ZIP CODE PHONE s WITH AREA CODE 54 O 95860,-iff;< N.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - 0 3 1 9 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ box bYdkab 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE I�1 SURE7Y10NO LETTER OF CREDIT =6 EXEMPTION D G 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: 1.0 II.O III. 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) OWNEWSTITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# +o44 07- 7.lt6l97 LOCATION CODE -OPTIONAL CEEN§RUSJRACT# -OPTIONAL SLS IISOOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BBYf(A�jTDOLEAST(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(3183) FOR=3AJR7