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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A y: <br /> ry, <br /> �4nonn✓ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 RMA CLO2 SITE <br /> ONE ITEM INTERIM PERMIT Q 6 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITYlSIT FORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL# <br /> GLi AK.�Pi (� <br /> CITY NAME nSTATE <br /> CA ZIP CA�� / I�PHONEW Ty A�F�,/u <br /> REA <br /> I/ Box TO INDICATE O CORPORATION INDIVIDUAL a PARTNERSHIP LOCAL-AGENCY 0COUNTYAGENCV Q STA - CY (�FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 52rI GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN 0 OF TANKS AT SITE E.P.A. I.D.#(option <br /> RESERVATION <br /> Q 3 FARM Q a PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> MAME <br /> ST,F STI PHONE A WITH AREA CODE DAYS: NAME(LAST,FIR <br /> r 3 5/L!a s 5/DZ—(LAST,F ST) PHONE#WITH AREA CODE N HTS: NAME( ,FIRST) <br /> PHONE 0 WITH AREA CODE <br /> TYOWNER FORMATIO - MUST BE COMPLETED(/ �+� CARE OF ADDRESS INFORMATION <br /> REET ADDRESS ✓E^ UxI Q INDIVIDUAL 0 LOCAL-AGENCY Q STATE•AGENC CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY STA ZJP CODE PHONE#WITH ARE CODE <br /> SPrN �r�l0 <br /> III. TAN RMA N-(MUST BE COMPLETED) <br /> NAME OF ER <br /> M INGORSTREET ADDRESS ✓ Ib micas ED INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> � fl M)AIt1 /ZA-M,gN CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CI AME 5m n _ ^^O STA ZIP CODE PHONE�57WITH AREA CODE rO 0 <br /> IV. BOARD OF EQUALIZATION UST ST VV 111Y1 \ 1 916 3223.9555 if questions arise. ' (Dy <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ W.biMkale D I SELF-INSURED p 2 GUARANTEE 0 3 RANCE O A SURETY BOND <br /> O 5 LETTEROFCREDIT a EXEMPTION G2199 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I I is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. I IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C RRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> 3�3o-9Z <br /> LOCAL AGENCY USE ONLY WiZ <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® G/f6vRS® 'f 101-01 V1 a <br /> LOCATK)N CODE •OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL r i7 411 <br /> O V ✓ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS I$A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORD033A 5 <br />