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1011100, *40 <br /> 'EbOVR: C <br /> STATE OF CALIFORNIA + <br /> STATE WATER RESOURCES CONTROL BOARD it b <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY 0 I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSEITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED P K 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> De AGILITY NAM <br /> GFj / w n I NAME OF RAT <br /> 5 f/G.CJ <br /> ADDR NEA S ROSS STAEET PARCEL#(OPrIONAL) <br /> CITYN E STATE ZIP CO Z0 SITE PHONE#WITH AREA CODE <br /> TOINDICATE D CORPORATION INDIVOUAL 0 PARTNERSHIP O LOCAL-AGENCY E=I COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE Of BUSINESS 0 GAS STATION 0 2 DISTRIBUTOR = q,/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optiawe <br /> 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA rnnP <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFO MATION-(MUST BE COMPLETED <br /> NAM <br /> ✓L/Aj�(/ / CARE OF ADDRESS INFORMATION <br /> Y` m <br /> MA S TESS lox t1rdRgs = INDIVIDUAL LOCAL AGENCY = STATE-AGENCY <br /> 0940 Dr`1/ <br /> � CORPORATION = PARTNERSHIP O COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NA�E� /` STATp{ ZIP CO PHONE 0 WITH AREA CODE/` STATp{ ZIP CO PHONE 0 WITH AREA CODE <br /> ( <br /> Ill. TANKOWNER INFORMATION-(MUST BE COMPLETED) /viii. <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREETADDRESS• ✓ box 0rvi a1B 0 INDIVIDUAL O LOCAL-AGENCY [7)STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP O COUNTYAGENOY M FEDERAL AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION <br /> �UST <br /> �STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 -( Iv--L-1-�✓I-FIJI <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ wbiMkam 0 I SELF-INSURED [=]YbUARANTEE 3 INSURANCE E=] 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION C] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O It. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAM E(PR IN TED 6 S IGNATU RE) APPLICANTS TIRE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 9 'I �hl6E lS .1� <br /> LOCATI -OPTIONAL CE2S ACT# -OPTIONAL SUPVISOR-DISTRICT CQD -OPTIONAL <br /> THIS FOR MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF I INFORMATION ONLY. <br /> FORM A(129A FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA ANS <br /> -- FOR0033A R6 <br />