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SEF'-20-94 TUE 03 :53 R OLL I NS LEASING 20994 8 4548 F'- 06 <br /> STATI OFCAL1Ft3OU + <br /> STATE WATPR RESURCES CONTROL.BOAItt3 + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> - <br /> COWLETE THIS FORM FOR EACH FACLItYt$n f <br /> MARK ONLY i NEW PERMIT a RENEWAL PERMIT a CHANGE OF WFORMATIONI ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E 2 NTERIM PERMIT Cj 4 AMENDED PERMIT 5 TEMPORARY SITE CL03VRE <br /> I. FACILITY,SITE INFORMATION&ADORESS-(MUST BE COMPLETED) <br /> NA OR FACILITY NAME NAME OF OPERATOR <br /> icCLLI _S L-6— k,'Ij, Ci2ty �"__!v iCi_Li <br /> ADGRE93 N EARS ST CROSS STREET PARCEL r(SaMNAL} <br /> ,Z C C L c:C,1-t I, r A <br /> CITY NAME r STATE ZIP CCOE SITE PHONE I WITH AREA CC <br /> 7'0IV CA .5 C c a-, 9 :i' — I-5 c <br /> 'O�IIOYGA7E COAFORATIDM INDNIDUAL ?AWNffiS?IIP [� LWAL-AGENLY Q COUMTY•AGERCY Q'3TATE40EkCr- FECERAL-A aENCY' <br /> OISTAICTB <br /> M cwnw d uST Ie s pubic M9eMY,a+r VMc.Ihr(onowing:�snw e!3upe(v rw al db$wn,sac7ian.61 Olfiet whkh apratm tha UST <br /> TYPE CIF AUSINE SS 1 GAS STA710N 2 DISTRIBUTOR ✓ IF INQIAM if OF TANKS AT SITE, E.P.A. I.D.a AWil (W) <br /> RESERVATION <br /> a FAFLM l PROCEMA_-mac s OTHER On TPU$-r LANOS C j1 I ccoS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PEMN (SECONDARY)-opilwat <br /> DAYS: NAME[LAST,FIRST} PHONE 1 WTI'H AREA 0006 DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> CAIS Ati I' �c?i� rl 3 7Z VALC ( tG ✓r -_l;G:ra <br /> NIGHTST NAME(LAST.FIRST) PHONE It WITH AREA CODE N04TS:HAIR (LAST,FIRST) PHONE I WIThi AREA CODE <br /> !C L`ll�:f- .Ji c�rLJ�. .SC�(•';CGr l yr'c' �J _ s%%7f <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NSE CARE OF ADORES&INFORMATION <br /> MAAIN(30RSTREET AQOuRESS ✓ xatF(dkw Q WIVpUAL Q LXAL,4ENCY l= STATE-AGENCY <br /> ? r9 f4 v6l(.-:,Y, <br /> CORPORATION Q PARTNER IIIC awlaryr Q FE: wL Ac,�NcY <br /> CITY NAME STATE 7 7P CODE PJ1HtE v WITH AAEA CCOCe <br /> 111. 'SANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OFOWNFA CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES$ ✓ bw iow"a* Q INOfYDWL Q:DCAL,IGENGY []STATE Ammy <br /> g". ,LJ E G t i i i �/� f5, Q COAXRATSON Q PARTNERSHIP ©GOUNTYJ,a?CY FEDERAL-AGENCY <br /> CITY NAME STATE 7JP CODE --T-PHONE J WfTH AREA CODE <br /> IV..ROARD-QF EQUALIZA.T1.014 UST STORAGE PEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ [4K C c <br /> ,y <br /> Y. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOU(S) USED <br /> ✓ bpc pixlkalr } SELF-INSURED 2 GUNWCME =3 NWRAWCE Q+SURETYBClND <br /> S LETTEROFt11ED1T C 1 EX wm0* C3 90 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal Ratil;uIon and bilmg will Lae rant to the lank owner 0aless box I or III$checkad. <br /> C<CM ONE'90-X INDICATING WHICH ABOVE ADDRESS W-,OULD BE USES FOR LEGAL NOTiPICATIONFS ANO BILLING: L C j IL <br /> THIS FOAAd H.4 S BEEN COMPLETE a UNDER PENALTY OF P-enjURY,AND TO THE HESt CF MY 00VC>WLEDISC,IS TFWE ANO CORRECT <br /> OWNER'SNAAAE(PRINTEDI SiGN£0) OWNEA'STIT'LE RATE MCNTIV AYNEAIR <br /> �.;���:c z�_�,� e .— Est-�%✓r-.zolt.f � <br /> LOCAL AGENCY USE ONLY 7 <br /> COUNTY I JL1F1tS0ICTION 0 FACILITY I I <br /> LOCATIOHCOOE -OPTIONAL M ICFN9USTRACTt_d7Prlot"L FiUPYiBOR•018TfiICTGODE �°Ta71LAi <br /> THIS FORM)AUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER>VIET A?PLIcATI011- FORM B,UNI ESS TH13 is A CHANGE OF SITE MIXIMATICr(!ONLY, <br /> OWNER MUST FILE THIS FORM WITH T14E LOCAL AGENa ImpLEIImmG THE LR(EG GROUND STtlRAGE TALC REQULATtC111s <br /> FORM A CM) SW <br /> ve <br /> LT t3 <br />