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} <br /> STATEOFCAUFORWA w�. •" <br /> STATE WATER RESOURCES CONTROL BOARD l <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACHFACILRY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PARCELa(OPIIONAU <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE a WITH AREA CODE <br /> CA 95937 <br /> .1 Box �) 74 5pv (� <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL AGENCY' <br /> DISTRICTS'II owner G UST is a public agency,complete the following:name of Supervisor of division,seclbn,or office <br /> which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS ATSITE ITP A. I.D.a(gwkW) <br /> e!i3 FARM 0 4 PROCESSOR 0 5 OTHER 0 RESERVATION <br /> OR TRUST LANDS C-/�G pop 7G7 6 80 <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 x WITH AREA CODE <br /> /-/oGGE read _ tZ us\V7�-Soo( <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAMEF�✓+ak A7 GGA CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS p -7-7 ✓ box bIndicant OINDIVIDUAL <br /> 17 06' / x 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> LDS oe GA �i5237 Za)777-S&c�6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Ssy <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> i� <br /> MAILING OR STREET ADDRESS '' /I'' q ✓ box birdkale 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 5 L ' L UYE �L D�, 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY <br /> O FEDERAL AGENCY <br /> CIN NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> CA g5Z37 fz�)�z�- SSG <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-14--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box biMkate 0 1 sal'INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT 0 6 EXEMPTION 0 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 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 1. e III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'STTL DATE MONTWDgY/YFAfl <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> L�!—J # FACILITVt <br /> LOCATION CODE -OPTi(1NAL CENSUS TRACTa -OPTIONAL 9UPVISOR-DISTRICT CODE -OP710NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FdRM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> • FOR0033AR7 <br />