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I STATE OF CALIFORNIA ooi STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 10 COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED.SITE //� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE OZ C I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FACILITY NAME G i" 4.o0✓Gc'SG7 NEAREST CROSS STREET PARCEL(OPTIONAL) ADDR S CITY NAME STATE ZIP CODE SITE PHONEp WITREA CODE /,0 CA a1 rJ VIL> & 3?--7 335`L ✓ BOX Q CORPORATION ED INDIVIDUAL (] PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' OSTATE-AGENCY' E:j FEDERAL-AGENCY' TOINDICATE DISTRICTS Hoemerof USTlsapubkagenry,00mplela NBlollDwng re eof supemor of ONlslon,section orapke which operates the UST ✓IF INDIAN pOF TANKS AT SITE E.P.A. LD.p(optionaQ TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATIONa. j F-13 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS f� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE 9 WITH ARE CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE '� ?_Z PHONEp WITH AflEACODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) If. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME ,a G-:42../ G.L2�.� :�� ✓ box to in&ate 0INDMDUAL (] LOCAL-AGENCY El STATE-AGENCY MAILING OR STREET A RESS li �� ✓� 0 CORPORATION 0 PARTNERSHIP [:3 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY AM STATE ZIP E _ /� PrN�E k WITH 7_CODE G 0 /7 /6`71 }Yrf _7I1 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME OF OWNER �✓ b INDIVIDUAL O LOCAL-AGENCYQ STATE-AGENCY MAI ORETADDRESS CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY Dao STATE ZIP CODE PHONEp WITH AREA CODE CITY NAME41, �`1 0A i 4 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to inCicete lFj 1 SELF-INSURED = 2 GUARAMEE E::] 3 INSURANCE I�4 SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND Q 9STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It fT 31�i I 77ZNI7Kk LOCATION CODE -OPTIONAL CENSUS TRAC14 -OPTIONA SUPVISOR-DISTRICT CODE -OPTIONAL ) ri Z'$ , O 3 v THIS FORM MUST BE ACCOM (l)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INF RMA ION ONLY. OWNER MUST FILE THIS FoRqr THE LOCAL AGENCY IMPLEMENTING THE UNDERGRq*STORAGE TANK REGULATIONS FORMA(6-95)