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STATE OF CALIFORNIA �����Vp�® ,' <br /> \ STATE WATER RESOURCES CONTROL 80ARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,o <br /> v o..,. <br /> COMPLETE THIS FORM FOR EACH F /SITE <br /> MARK ONLY 0 i NEW PERMIT S RENEWAL PERMIT CHANGE OF INFORMATION Q 7 LY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT a ♦ AMENDED PERMIT S TEMPORARY SITE CLOSURE Q / <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> Giry ,Y, <br /> ADDRESS NEAREST CROS%STREET PARCEL#(OPTIONAL) <br /> `jl <br /> CIT!NAME ST CA ZIP CODE 9 x S PHONE <br /> ONE,WITH AREA CODE <br /> v SOX IF <br /> TO INDICATE (] T CORPORATION O INDIVIDUAL Q PARTNERSHIP a LOCAL-AGENCY 0 COUNTY-AGENCY C; -AGENCY OP03JFFEE0-ERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. L D.i I000eal) <br /> 3 FARM 6 PROCESSOR S OTHER RESERVATION <br /> Q Q OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME.N.AST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /44 N —9.1-5-4 <br /> NIGHTS: NAME(LAST,F S-n I PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWONF Y"TH AREA <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Oaxnl^aicua Q INDIVIDUAL I3 LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION [--] PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 5^+p Yn m Q INOIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> I�CORPORATION a PARTNERSHIP M CWNTYAGENCY C1 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ RE- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> J Om oviNcaM Q I SELF-INSURED a 2 GUARANTEE 5 INSURANCE Q A SUREiV SONO <br /> a 5 LETTER OF CREDIT Q a EXEMPTION O 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 /> CNECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 11.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA W TED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION N FACILITY N, <br /> G�tL?�27 <br /> LOCATION CODE -OPTIONAL (CENSUS TRAC2T -8OPP,ONAL ISUPVISOR-DISTRICT CE -OPTIONAL <br /> J <br /> THIS FORM MUST BE ACCOt�1PANIEO 8Y AT LEAST(t)OR MORE PERMIT APPLICATION- FORM ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A I$-311 (rte` 1 POR0073A5 <br /> 1 � <br /> \ I <br />