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• a STATE OF CALIFORNIA •STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION" FORM AA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY t NEW PERMIT 3 RENEWAL PERMITIs 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE . / I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAR TCROSS TREPARCEL#(OFIONAL) er- CITY NAME v BOX STATE ZIP CODE ITE PHONE#WITH AREA CODE dam= CA _ O (Zo1)ri TO INDICATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTYAGENCY' DISTRICTS' O STATE-AGENCY' Q FEDERALAGENCY' If owner of UST is a public agency•conplete the following:name of Supervisor of ebielon,section,or office which operates the UST TYPE OF BUSINESS��-t GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.0.i(optimal) 0�3 FARM = 4 PROCESSOR 5 OTHER RESERVATION O OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE o S' Z� 9 3-Z0/ NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fl. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME �I CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMbale 0 INDIVIDUAL [�:j LOCAL AGENCY Q STATE-AGENCY SO 7 / ED CORPORATION O PARTNERSHIP COUNTY AGENCY Q FEDERAL-AGENCY CITY NAME STATSt ZIP CODE PHONE M WITH AREA CODE Gop�- d_YI 9 Z 9�3— a III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER ,-67 P. OF ADDRESS INFORMATION - i3, MAILING OR•STREET ADDRESS C ✓ box bindbale D 0 INDIVIDUAL LOCAL Q STATE AGENCY v I, VG CORPORATION 0 PARTNERSHIP � COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODEP ONE#WITH AREA CODE —arvc Z 9 3-T�i 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 b indicate = 1 SELF-INSURED 0 2 GUMANTEE 3 INSURANCE O 99 OTHER 5 LETrEROFCREDIT Q 6 EXEMPTION O 4 SURETYBONG VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESSSHOULDBE USEDFOR LEGAL NOTIFICATIONS AND BILLING: I.= II.[--] H.[X 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE - NAL le-9. 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 FORMA(3/83) 0 41 Y FORee33A.R7