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U. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A n�� ye C LETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT n 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR P r c c� Pi (ci G-Es Co , ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) /'30S� G.'�lsvh � CITY NAME / /- h ! � STATE ZIP CODE� 1 v� SITE PHONE#WITH AREA CODE Sa 4 7 v Y ✓ BOX TO INDICATE CORPORATION IINDIVIDUAL = PARTNERSHIP F-1LOCAL-AGENCYCOUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM U 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 13 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA/CODE DAYS: NAME(LAST,FIRST) _ Jia V -v� PHONE 4 WITH AREA NIGHTS: NAME(LAST,FIRST) PHO E# IT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �- II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME �1 CARE OF ADDRESS INFORMATION r7 r GD �rD ��5 �• MAILING OR STREET ADDRESS ✓ box 10indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY P� 0 x BCS j„ D—;?Oc" CORPORATION PARTNERSHIP (] COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME w STATE ZIP CODE PHONE#WITH AREA CODE /4r siw ?0 w 3/ - �fv7- �- vs— III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION _ .3 c4 tt--e t-t MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 14 H0_1 I0.1 O 5 D to V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE MET D(S) USED ✓ box to indicate L— 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 14 SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION = 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 the d. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. r- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Mco/9 O/ .3q LOCATION COD OPTIONAL CENSUS TRACT t-OPTIQNAL SUPVISOR-DISTRICT CODE -OPTION THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI - FOR0033A-R6