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SATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL 30ARO y� „�--• <br /> a. <br /> C� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR '. A <br /> COMPLETE THIS FORM FOR EACH-r !TYISITE <br /> .NARK ONLY I_: I .MEN PERMIT 2 RENEWAL PS;MIT S CHANGE OF INFORMATION i_ T PERMA EVTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a AMENDED PERMIT I d 'cMPORARY SITE CLOSURE <br /> I. FAC(LITYlSITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> 03A UA PAC:UI, NAME �e / NAME OF OPERATOR <br /> 40CAESS NEAREST CRCSS STREET PMtCEL,(CPTICNAU <br /> N Z <br /> C:r. Va`.IE / I STATECIAI ZIP C OE_ A SITE ARP CODE <br /> 50 <br /> TOINDCATE ,.RPCPArCN Q �NOrvCUAI _ PWTNERSwP Q LOCAL OSTW.AGENCY Q COUNTY AGENCY C SATE AGENCY Q FFSERAI AGENCY <br /> p¢racTs <br /> 1-5 OF 3USINESS 1 S STA71ON 2 usmauma ✓ F iNC1AN .CF <br /> TANKS AT SITE E-P.A 4 D.•(oPlmal) <br /> RESERVATION <br /> O •ARM A P40CESSCR f—1 5 OTTER OR TAUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> :AYS:.SAME(LAST.PAST PHONE a wl H AAEA O E DAYS: NAME a-AST.FIRST) <br /> «/ a 6 <br /> NIGHTS: .MAME(LAS T/ <br /> [RST) PHONE a WITH AREA CODE NIG ITS: NAME(LAST.FIRST) <br /> PurVc a•MTA ARca r^re <br /> 11. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME -/w n ,/ �' GREOFACCRESSWFORMArICN <br /> aAlLl`.G CR BTAE-=AOC ESS (/N!'7`� �l J ba o+nrm ;� <br /> y� �11-n / Q :NOIVCUAL C LOCALAGFNCI' iTAT'rAGEYCv <br /> 0 W 1/e/ V�/ Q CCRaMTION f1 PARTNEASAP ` COUNn_AGENCY r EnAL.AGENCY <br /> C;TV NAME ISTATE ILP CODE O I PHCNE a WITH AREA CODE <br /> III. TANKOWNER INFO RMATION-(MUSTSE CCMPLETED) <br /> NAME OF OWNER ^ �1 ---f CARE OF ADDRESS INFOAMAY.CN <br /> ✓\ �J /l/� a/'Jt� 1� <br /> MAILING OR STREET ADDRESS ✓ Pa nm <br /> Q Nolwuu u tau-AGENCY Q mTE-AGENCY <br /> Q COPXAArION Q PARTNERSHIP Q COUNTY.IGLINCY Q FESERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE i PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 iuestions arise. <br /> TY(TK) HQ 4 4 -�� J ®U� G� �� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> J m eMear IQ I SELF NSUREO I-:2 GUARANTEE Q S INSURANCE Q A SA m X110 <br /> IQ S LETTER OF CREOT Q a EmwmN Q W OTNER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilicalion and billing will be sent to the tank owner unless or II is checked. <br /> CHECK ONE BOX INDICATING WHICH AaOVE ADDRESS SHOULD aE USED FOR LEGAL NOTIFCATIONS AND SALNQ L Lf IL a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME{PRWIcD a SIGNATURE) APPLCANTS TITLEDAIS MCNTWDAYYEAR <br /> 9Z <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s JURISOICT:ON a FAC;LnY l <br /> EF] 5�rn <br /> LCCATgN DOLE -OPTIONAL I CENSUS TMLMCTa •f.P T JL I <br /> MSUPVISOR-DISTRICT CODE -CPTNJNAL <br /> THIS FORMUST BE ACCCMPANIEO 3Y AT LEASSST(T)OR MORE PERMIT APPUCATION- FORM B,UNLESS THIS IS A CHANGE OF SITE WFORMATtON ONLY. <br /> FORM A(5.31) fCAOAS2M3 <br />