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STA—lc Cf L;FCRNA <br /> STATT E'AATER RESOURCES CONTROL WARD `%C` f• `'-, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR M A <br /> COMPL ERE THIS FORM FOR EACH FAC,LRYfS(TE <br /> .MARK ONLY t .vEw PEaNrr ^ 5 ;E.NEWAL RERNIr LY C _ <br /> CNE ITEM C.4NCE CF ,NfCRugPICN 7 PE.iNANENT <br /> 2 'NTE.-.IM peRNIT a ANENCE7 PfpNR <br /> I d c.VPOpARY SITE CLCSUAe ( I� <br /> I. FACLITYiSITE INFORMATION 3 ADDRESS•(MUST BE COM <br /> PLcI ED) <br /> aACR:AG:U YNAyE aF S . <br /> VANE OF CPE.'+ATCR <br /> ACCRESS <br /> V � <br /> / n �� NEAaE$T CaC.STRE:T I ➢.wG'.,L.;CPfCn.V) <br /> Ca NA•.e ICJ �7 <br /> I STA iE I SITE PION awl, apEA C�CE <br /> v— � <br /> J Icz I CA <br /> TCINOCATE 'Q CCRPCAACCn Q:NONCUAL ?,R %EASW Q LOCAL. <br /> AGEVCI' r <br /> OISTRICTs Q COUNTY AO"r..'CY C STATE-AGEMCY <br /> Q %E EPAL GNCy <br /> TYPE CF 3lSINESS ,� <br /> I GAS$TA i l0 V l� j CLSTRIaUTOR QJ '.f NC4N s CF TAV%$Ai$I i E E.P.A, L O,A lPpnylm! <br /> J FARM r^ A PgcczSSCR r•7 5 OT-EA OR <br /> TRUST LANOS <br /> EMERGENCY CONTACT PERSCN (PRIMARY) -EMERGENCY CONTACT PERSON (SECONOARY)-optional <br /> LAYS:NAME(LAST,FIaTlPNONE A NITA AREA COCE <br /> DAYS: NAME{UST.FIaSt1 <br /> NgMTS:.VANE{LAST,RRSI PMCNE A'NITi1 AREA CCOE ° <br /> NGMTS:.NANE(LAST,FIRST) <br /> PvNe.YRry APeA r•vc <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME <br /> CARE OF AOCaESs WFORNArICN <br /> V a,l^.G Cp STREET AOCRESS <br /> eee¢nA <br /> Q INOVOUAL Q LOCAry,,S CY Q i,A�.AGElICY <br /> Q CCaiCRATCM Q P4'IrhEi4iR -,L ,Cy r- <br /> C:kv NAVE Q CWNrY -_E:LL+GEI+CY <br /> STA,c I ZIP G^,CE I PMCNEA WITH AAEA C.^.CE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> 11 ECFOWNER <br /> CARE Cf ACDaESS WFCauAT;CN <br /> NAICNG CR STREET AOOpE55 <br /> I aaorocua <br /> Q 9OIVp!!AL Q LOC,Y.AGFNCT <br /> Q WMRATa)f1 Q PMarIFJLSMp Q F MgAAG%G;., <br /> IXTY,wNE Q E^UNr/�AGE,rC'r Q FeT,FAML+KiJC/ <br /> STATE I Z1P COOS I PHONE A WITM AREA COLE <br /> IV.BOAAD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cali(916)323.9555 it Gues5Gns arise. <br /> TY(TK) HQ F4-1471-,(T <br /> V, PETROLEUM UST FINANCIALRESPORESPO�N3(LB,ILITY•(MUST BECOMPLETED)—IDENTIFY THE;METHOO(S) Uc 0 py <br /> J§u s.rea Q I SELFANSUAEO <br /> Q S kErrEACFCAEOR L j CIIAAAmu 0 5 A6URANCE Q A SWETY LINO <br /> 1'-S 91EVPRON Q g OTHER <br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS Legal notiri ation and bUing will be sant to the tank owner unless box I or II is checked, <br /> CMe"ONE BOX WCICA;M W ICH A3CW ACCRESS SWC=aE lSEO FOR LEGALNOrw CATICIM AND 9471a <br /> L❑ 0.c] IR G7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST CF AA'KN <br /> APPL.GW rS NAV E IPawrO a SGNATUREI OWLEDGE-!S TRUE AND CORRECT <br /> APw cANrs rknE <br /> NCNrwDArnEAR <br /> LOCAL AGENCY USE ONLY 'Z IL <br /> A..J <br /> COUNTY t �`' JURISOICT:CN e <br /> -It, ICw I T✓IA 6-JAZl—= FACIITYe <br /> LOCAIN7N CODE -CFIT,DLNML,�� <br /> II <br /> Ca:NSUs TRACT .rplgNMl wPV R. <br /> �Z 0 YaICi CODE •fAr1ONAl <br /> THIS FOA1A'RUST SE <br /> FORK A(5.4 1) ACC.^.MPANIEO 3Y AT LEAST(T)OR MORE PERMIT APPUCArON• FORM 3, UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FCRO=A3 <br />