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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® I NEW PERMIT ,Q 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED,SITE <br /> ONE MEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT © S TEMPORARY SITE CLOSURE �q <br /> ,1 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 03A OR FACILITY NAME NAME OF OPERATOR <br /> Katzakian Property Art Katzakian <br /> ADDRESS ....-...-_ NEARESTCROSS STREET PARCEL F(OPTIONAL) <br /> 15431 Lower Sacramento .Rd. Taylor CITY NAME STATE AP CODE SITE PHONE WITH AREA CODE <br /> CA 52 __ <br /> ✓ BOX [71 CORPORATION M INDIVIDUAL 0 PARTNERSHIP Ej LOCAL AGENCY ED COUNTY-AGENCY' C3 STATE-AGENCY' [] FEDERAL-AGENCY' <br /> TO INOICATE DISTRICTS <br /> B o"poi UST a e PUNO ARAry,aMlete the T01bwe g:name of SUPGNeWQl division.Be-om oroft which melds the UST <br /> TYPE OF BUSINESS Q 1 GAS$TAnom © 2 DISTRIBUTOR IF INDIAN 14 OF TANK$AT SITE I E,P.A. I.D.4(apticep)) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 5 OTHER on TRUST IANOS 1 CAC 001 267976 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY$: NAME(UST,FIRST) -�--• PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> Katzakian, Art _J916)682_aZ48 <br /> NIGHTS: NAME(LAST,RRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> XXX4 katzakian, Jerry209)951-2000 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Art Katzakian <br /> MAILING OR STREET ADORES3 ✓ box t0 i4ahe X3 INDMOLIAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 10241 Sheldon Rd. ©CORPORATION ©PARTNERSHIP COUNTY•AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Elk Grove _A _ <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Art Katzakian <br /> MAILING OR STREET ADDRESS INDIVIDUAL [LOCAL-AGENCY C]STATEAGENCY <br /> 10241 Sheldon Rd. Q CORPORATION R PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R WITH AREA CODE <br /> Elk Grove <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HO [414- -I I I I � j <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓LpN 1p iMiR,te Q 1 SELF.IN$UPEO 0 2 GUARANTEE L]3 INSURANCE I=a SURETY BOND (-1 5 LETTEAOFCREDIT In B EXEMPTION C)7 STATE FUND <br /> VJ B STATE FIRID a CHIEF FINANCIAL OFFICER LETTER 04 STATE FUND 6 CERTIFICATEOF DEPOSIT 010 LOCAL GOVT.MECHANISM (] BB 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' I. II.r1 HL Q <br /> THIS FORMT HAS SEEN COMPLETEO UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> TANKO R'$ E(PRINTED&SIGNATU ) TANK OWNEWS TITLE GATE MONTH/DAYIYEAR <br /> cr Th9 e for Arty Katzakian owner 9/9/97 <br /> "IbCAL AGENCY USE ON Y �— <br /> COUNTY F JURISDICTION R FACILITY 0 0077/0 <br /> [Ti *3•P/ 1610 171 / 3 8 <br /> LOCATION CODE •OPTIONAL CENSUS TRACT a •OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL AR <br /> ra Y7 <br /> THIS FORM MUST BE ACCOMPANIED BYST(1)OR MORE PERMIT APPLICATION- FORM B,UNIS IS A CHANGE OF E INFORMATION ONLY. <br /> ' uI15T FILE THIS FO WITH THE LOCAL AGENCY IMPLEMENTING THE UNDER AD STORAGE TANK REGULATIONS <br />