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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Q'Z <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> GoAS� �'o✓�#dS <br /> ADDRSS —'--246'4—/ <br /> NEAREST CROSS STREET <br /> y PARCEItl(OPRONAy <br /> CITY NAME STATE ZIP CODEITE PHONE X WITH AREA CODE <br /> CA 4--715Z�Da9 33.1- -335Z-- <br /> v <br /> 352.✓BOX Q CORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY D COUNTY-AGENCY' 0 STATE.AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'N ownerof USTis a public agency,complete the folnwng:noma of sgernsord tlNunn,section oro#me wItidloperetes the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESVIFINDIAN ERVATION X OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(Lp�FIRST) PHON-Tp W-I�TH AR Do335 DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AGS Fi <br /> MAILING OR STREET A RESS r C ✓ box to ndrate I� INDIVIDUAL Q LOCAL-AGENCY 1� STATE-AGENCY <br /> �L O CORPORATION I� PARTNERSHIP Q CgOHUNTY-AGENCY / l� FEDEERRAALLAG�E,yN.CYY <br /> H AREA DE <br /> CITY NAM �.� STATE ZIP�ODE � }jOONE }NIT�67— p S'-"--' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CO <br /> '/T 5 C �J/1 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,QGAiFiG G�AsT'�gpv <br /> MAILING OR STREETT ADDRESS ✓ boxtontliwte D INDMDUAL O LOCAL-AGENCY ID STATE-AGENCY <br /> -000,9- ED CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGETIG <br /> CITY NAME STATE IF CODE PHONE It WITH AREA CODE <br /> Laa?- g�2�o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indnate 0 1 SELF-INSURED O 2 GUARANTEE M 3 INSURANCE =4 SURETY BOND O 5 LETTER OF CREDIT =8 EXEMPTION I1 7 STATE FUND <br /> O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orr11 ids•checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II,y� III.C <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al FACILITY#3 1 E <br /> 3� F-71-1227 Sj <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3Z C;,' <br /> THIS FORM MUST BE ACCOMPANIED BY AT�(1)OR MORE PERMIT APPLICATION- FORM B,UNLE� t <br /> FORMA(695) IS IS A CHANGE OF SITE INFO <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIO' <br />