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4 STATE OF CALIFORNIA b STATE WATER RESOURCES CONTROL BOARD w;„„� p UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ?p �s j o ry� COMPLETETHIS FORM FOR EACH F CILITYISITE FMARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME ^ ' �. NAME OF OPERATOR G /Z— PC' CROSS PARCEL#(OPrIONAL) / � ADD EBB � � � ^ F,. SAC'AGIJ �f)Gyl AREA COGE CITY NAME �. TOI/ BOX INDICATE 0 CORPORATION INDIVIDUAL l7 PARTNERSHIP 7_1 DISTRICTS ENCY Q COUNTY AGENCY STATE-AGENCY Q FEDERAL -AGENCY TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 RESERVATION 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CO r DAYS: NAME(LAST,FIRST) of 5v/J/,/W 365- P� ZDu�klc*WITH AREA COOP NIGHTS: NAME(LAST,FIRST) PH E%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) kvVI II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION C ✓ box bIndicate INDIVIDUAL O LOCAL-AGENCY I� STATE AGENCY MAILING OR STREE ADDRESS O � w 0 CORPORATION � PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL CITU NAME STATE ZIP COOED. PHONE n WITH AREA CODE GjL,)-- _LJ, III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME FOW ER CARE OF ADDRESS INFORMATION v / AILING OR STREET ADDRESS ✓ box blMicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNIV-AGENCY FEDERAL AGENCY CITY NA E U/ STATE- ZIP CODE PHONE a WITH AREA CODE 11-ppT IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4_F4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ohdIcale 0 1 SELF INSURED Q 2 GUARANTEE 3 INSURANCE L_j 4 SURETY BOND [71 5 LETTEROFCREDIT D 6 EXEMPTION D 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.I] III.E THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# � LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 1 :R? I _nzo! THIS F RM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(591)