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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> ^ e <br /> 'GSOV <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> a <br /> 0 <br /> .: os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM L ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE rO <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 7 <br /> DRA OR FACILITY NAM <br /> G���2 y NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET T PARCEL IN(OPTIONAL) <br /> CITY NAME O ��- �J_/L-� "-TQ^ S / <br /> /10= I STATE ZIP CODE q SITE PHONE x WITH AREA CODE <br /> Box TE CORPORATION CA / Z�� <br /> TO INDICATE <br /> 0 INDIVIDUAL O PARTNERSHIP [] LOCAL-AGENCY <br /> TYPE OF BUSINESS DISTRICTS COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I,D.# <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ❑ RESERVATION (poll <br /> Elio <br /> LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> Days: NAME(Last,FIRS NWITH AREA CODE EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAM (LAST,FIRS /�/{/L{®�PHONE A WITH�ARE2A COCDJ�^E V <br /> NIGHTS: NAME(LAST,FIRST) <br /> It. PROPERTY OWNER INFORMATION• <br /> NA MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD!R.ESS - 1- <br /> ( 7�� 6�'4� -- box Inndi a I� INDIVIDUAL <br /> - I Q COCALAGFNCY 0 STATE-AGENCY <br /> CI 0 CORPORATION 0 PARTNERSHIP Q CUNTY-AGENCY �FEDERAL-AGENCY <br /> STATE ZI�pE_ HONE#WITH AAREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAA�OF OWNE � <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OORSTREET ADDRESS <br /> /715/ W. .5;IA I [' 141, ✓box I inOkale INDIVIDUAL <br /> CITY N ME 7-'� '`/ I�CORPORATION 0 ry.AGELOCAL-AGENCY = FEDERSTATEAL-AGENCY� PARTY flSHIP � COUNTY-AGENCY Q FEDERALAGENCY <br /> r/ S� 0 STATE, ZIP CODE <br /> d5-I4 i-.x L) HONE#y�ITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(C7 323(1-9555 if questions arise- 1 ZZ —gZ/U <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz Io iiWicale [_] I SELF INSURED 0 2 GUARANTEE <br /> L� 5 LE1TEfl OFCREDIT 0 6 EXEMPTION 3 INSURANCE d SURETY BOND <br /> C %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 /> I <br /> ..THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISTRUE AND I CORRECT II.F-71 <br /> APPLICANT'S NAME(PgINTEO 8 SIGNATURE) <br /> APPLICANTS TITLE DATE <br /> MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> =1' <br /> JURISDICTION tt <br /> IFACILITYtt_ � �� p �'Tp - ------ ���aOPTIONALUPVISOR-DISTRICT CODE -OPTIONALHls FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION-ORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 FOR0033A A6 <br />