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STATEOFCAUFOFNA <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 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION -Z07 PERMANENTLY <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE / <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEp1 F OPERATOR <br /> P-A71k C'09 <br /> ADDRESS n^� _ � NEAREST CRO STREET PARCELN(OPrONAIJ <br /> CITY NAME GA'v'lX STATEZ�I•PO`W'/J1 SITE NENW EA CODE <br /> Cgt.t�o,enl� CA <br /> TOI/ BOX <br /> INDICATE D CORPORATION O INDIVIDUAL ED PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' FATE-AGENCY' ED FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a public agency,complete the following:name of Supervisor d division,section,w off im which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN N OF TANKS AT SITE E.P.A. I.D.N(opllanaf) <br /> ❑ 3 FARM ❑ 4 PROCESSOR W 5 OTHER OR TRUST LANDS <br /> MACTPERSOI ( EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NEN ITH AREA CODE RNI <br /> NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 2��a gig s -� <br /> NIGHTS: NAME(LAST PH N WITH AREA CODEy�� S: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I. Y-OWNERINFORMAfi10 'f�E00MPLETED D <br /> MEI CARED ADDRESS INFORMATION L1, <br /> aG olo�p <br /> MAIL GOR STREET ADDRESS ✓ box blydkab O INDIVIDUAL 0 LOCAL-AGENCY TATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 11 FEDERAL-AGENCY <br /> CITY NAME , �-'Goe 16I STATE ZIP DE HONE WITH AREA CODE <br /> t/N^/ t <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> AME OF OWNER CARE F ADDRESS INFORMATI N <br /> c,F E <br /> MIULINJI OR STREET ADDRESS I ✓ bDxbindicate = INDIVIDUAL O OCAL-AGENCYSTATE-AGENCY <br /> ( O CORPORATION O PARTNERSHIP D COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITYME STATE ZIP CyD€�qr .Yt�f Q �]TADyI <br /> NN H AREA CA—/43 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arriLise, <br /> TY(TK) HQ M44- - St2ZC T5Wl< <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ bexbindbate = 1 SELF-INSUREO =2 GUARANTEE i� 3 INSURANCE 4 SURETYBOND <br /> O 5 LETTEROFCREOT EXEMPTION 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 /> Izo <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II AU <br /> III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OW ER'S NAM TED851GNED) e� O TITLE DATE MONTHfDAYNEAR <br /> LOCAL AGENCY USE ONLY Zv1 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION -OPTIONAL CENSUSTRACTN -OPTIONAL 9UPVISOR-DISTRICT <br /> TICODE -OPTpAUL <br /> 4 <br /> RI ©(90 <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> y `j y 10MIA,117 <br /> ..FORM A(3/831 1 Fg <br /> L Gj <br /> v �� / <br />