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STATE OFCALIR7RNL ` <br /> -.: ' -��` <br /> QJ i Aic WATER RESOURCES C`NTROL BOARD ! * f�_ ul� <br /> RGR tdD STORAGE TANK PERMIT APPLICATION wtRU A: <br /> n <br /> COMPL c"T'c THIS FORM FOR EACH FACIA-RSITE -; :!'` - P b n n <br /> .HARK ONLY NEW rERMrt �J 3 AENEWAL PERMIT I� S CNANOE OF '.INFORMATION 1 PERMANENTLY CLOSED STe <br /> ONE ITEM I_ 2INT'ca1M -Gama '_I a "ENDED PERMrt I 3 TEMPORARY SrtE CLOSURE <br /> I. FACILITY/SITE INFORMATION dI ADDRESS-(MUST BE COMPLETED) �A <br /> OSA OR FAC:UTY.NAME I NAMEOFcPERATOR r <br /> Aaco r ra a _4__�> !?.S.T.. X02 <br /> ADCRESS I NEAAEST CROSSSTREci I Pwa,(DPIIONAU <br /> 50\ U) AV�-cv'%Nt <br /> CrIYNAME STATE 11PCOOE SITe?NONE a WRM AREA COOS <br /> Lo� I CA gsL-s o X204 :�3 <br /> . 3caaRAoON .^INNY L .ZI PARINEASMP UOCAWGRI.Y �`:ccUNn.M5r71e'r I� STATE-AGENCY ; SULL+Da1LY <br /> -O1xOCACAIE roUA --� <br /> =facts <br /> TYPE OF 3USINESS i� ( GAS STATION ;� 2 OISTRIBUTOR C RESEIF RVATION s CF TANKS A7 SITE :P.A. L J.,!a*AnM/ <br /> (� T FARM U A PROCESSOR 11 5 OTHER OR TRUST I QS I 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <br /> GAYS: NAME/LAST.FIRST PHONE.�"TH AREA G)OE DAT$:NAME tLAST.FIRST) YiOO <br /> )'\Aa1ACezR Ota 't. -T-1 �7-L�y1 3�3 -Ol`k I x9m �1A\�C2NS OJNCo r <br /> NIGHTS: NAME(LAST.FIRST) PMCNE.WITH AREA W'OE NKNTS:""(LAST,i;As-n 400 -�•12 -la 1`\Ol <br /> 1^111MA - ON btTJ <'2d� 333- lVl A(lC0 fM\flAAvTe,J eu�ce r F, aRFA <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME I CARE Of ADDRESS RIFORMATION <br /> ARcO �\ Ica Ccr, Nv � E�sS <br /> MAILING OR SHEET ADDRESS T� m°•� _ ADNOIML UO(:M.AGHII.Y — ;rATBAc.T3N.Y <br /> �OL lao S� I ' COMMMN PARTV.WW OUlay4Gax.Y �'Yi IL.WM11Cy <br /> CITY NAME STATE AP cam PHONE,MTH AREA CODE <br /> T=sLa Ca. X02- 03S-�C�lv� bio-s=.0= <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> .NAME OF OWNERI CARE OF ACDRESS IW.QFI"TON <br /> tN CZ;.o �T-a v cln 'm Ccv) A -4 G T a S <br /> .uAIUNG CR ST,AEET ADDRESS1 J m o.® INDIVIDUAL -7 CAL4Ca0CY U — STAT--,AGS?CT <br /> `003 I �!OORNII lm � RARTNERw -'COurm-AGFALY � mew-ACrNCY <br /> CITY NAME 'STATE I IID^C'OE r`IONE cW1TM ABEL CC.�E <br /> ,si.a Ca G0-102- b <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(416)323-9555 if Duesdons arise. <br /> TY(TK) HQ 4 4 L 01 al U I SI 01 b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST3ECOMPL_ice)-IDENTIFYTHEMETHOD(S) USED <br /> J m ewcaM <br /> 31 SEURNSUNED ?'+11ANAxrEn ]WSURANL'c Q a SURETY 90x0 <br /> 5 UZ rSOFOIEDr d EAEAPwN A OrNEa <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal naffiialim and billing will be sem to the tank Owner union box I or II is dadc,ll. <br /> CHECK ONE 3OX NOICATING WMICM ABOVE ADDRESS SHOULD n USED FOR IEGALNOTWATIONS ANO W-MG' L i= IL= I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY OCNCWLEOGE IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRwTTEDa scGATUR`E') APPLIC.WT'S TRLE\\ , \ DATE M_O\\N ri'/EAR <br /> LU��1Arr� „�. �.J�CA I�UN �,(e,- El .�DmJttp,vicz 3�mL+J . l LJL q $ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* �J JURISOICTION* FACMAY; - <br /> I X13_ 113 41 <br /> LOCATION CODE -OPTIONAL CENSUS TRAC,-OPrCNN. S'l1P/150R-OLSTAK:T CCOE OPrIONAI <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) r 5 <br /> To'. �MSorlmv.lvCo .�Pu1o.4�e'r�SveS �P-0, �o:c2orA STc�''bw Cq . ��a01 �'(�'a'A(� �/ <br />