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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 FACILITYISITE (� <br /> MARK ONLY 1] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM [::] 2 INTERIM PERMIT Q # AMENDED PERMIT E:j a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Vivian Gatzert Property <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 500 E. Oak St <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX Q CORP -I [__1PARTNERSHIP EDLOCAL-AGENCYO COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '#omerol USTBapublkageoq, wI the I in r o olsupernsorotdivision,saftnoroffmMNopealeslhe UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.it(optional) <br /> Q 3 FARM Q 0 PROCESSOR RESERVATION 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> # DAYS: NAME(LAST,FIRST) PHONE#WITIOREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHO E# I ODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATICIN <br /> Vivian Ltzert <br /> MAILING OR STREET ADDRESS ✓ bas torxrale �]r INDMI UAL <br /> LOCAL-AGENCY DSTATE-AGENCY <br /> O CORPORATION O PAR SHIP E:)COUNTY-AGENCY E:j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> GA f�AQ�Q65 6652 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATI N <br /> Vivian qatzert <br /> MAILING OR STREET ADDRESS ✓ box to Md'wxte [:(wDIVI AL OLOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME --��---'^"�•'-"--""-"'"-` ATE ZIP CODE PHONE#WITH AREA CODE <br /> LQ ; <br /> IV. BOARD OF EOUALIZ TION UST STORAGE FEE ACCOUNT NUMBER-Call(916)-322-9669 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to lMicate 0 1 SELF-INSURED 0 2 GUARANTEE Q 3INSURANCE Q 0 SURETYBOND O 5 LETrEROFCREDrr =6 EXEMPTION O T STATEFF ND <br /> E STATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 19 LOCAL GOVT.MECHANISM = 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> Q.. <br /> TANK OWN 'S NAME(PRINTED&SIGNATURE) L OH N OWNER'S TITLE _73/9/98 <br /> ATE MONTHIDAYNEAR <br /> Ly OWNER 3/ / 8 <br /> OCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. <br /> FORMA(6-96) OWNER MUST FILE THIS FORTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROS STORAGE TANK REGULATIONS <br />