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STATEOFCAUFOFWIA ice; <br /> ATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGRO D STORAGE TANK PERMIT APPLICA 1 = C ' "¢ <br /> ao <br /> FEB 0 3 1992 <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITI[III I i TH <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFOR4Ap11 SfI"4M-Y CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> tE5CXpw 7-3330 RANDEL.L. F . VerTG-!5;Y <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> °.5126 W- SeK.IJAmiN HOLT DiztvE 4t,C,l9F3Y <br /> CITY NAME STATE ZIP CODE S TE PHONE#WITH AREA CODE <br /> Sfo�KToL.I/ CA 952c7 �2 -1)A7$64ol <br /> I/ BOX <br /> TOINDICATE LYI CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY ED FMRALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSEj� GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN #F-4 <br /> KS AT SITE E.P.A. I.D.#(gptmW) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS cAp qg I R I IZZ�o <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST.FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) P E#WITH AREA CODE <br /> exp (.ON FIEL-D �N®1NE62 (.41S)Zk687Z6 t Z FIeLD r--W6IrJ�rZ �S)Z44e,1 16 <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> �GCo 4 C�iM G�hll�� CBc.�)�1�123647 eU(ON clgm GGNTe2 CBoo� 12r�(os}7 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION v-vegrEB21.1 LZE6-IcN <br /> e�,VoN CoMPANY, L)SA APM1"10TV,&To12— <br /> MAILING OR STREET ADDRESS bindkaN INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> e}CL_d I7AGONiA2 3— Fto4�¢ CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ONE#WITH AREA CODE <br /> W*,..) oN Te 77a1a �oo�at�t236A7 <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> >:yC�N COMPAN`(, v� PLAlb2Y dGNtIN15ri2droZN <br /> MAILING OR STREET ADDRESS eD box"F- = INDIVIDUAL ( LOCAL-AGENCY =STATE-AGENCY <br /> 'DAG,pMA T 7J'— rL00P— [CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE NE#WITH AREA CODE <br /> HcLJSToN 7� 77cwlZ eoo) 012364-7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 0 0 0 2 ,05 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O II.R� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANDCORRECT <br /> APPLICAN"S INUIS eamweRE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> MUM Maya G l ZED 192 . <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY ar <br /> 391 EXXON 3/ LLLI 1 1119Z° qZ <br /> LOCATIONCO -OPTIONAL CENSUS TRACT#- FS -DISTRICT CODE -OPTIONAL <br /> p 2-31 ,C"�"` z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOHom3A a2 <br /> FORM A(&SO) <br /> 1A_ <br />