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SEP-21-94 TUE 08 :53 ROLLINS LEASING 2099484548 P. 06 <br /> STATE OFCALIADRNIA <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH FACtU dWM ~� K <br /> MARK ONLY _ <br /> f NEW PERMIT E] 3 RENEWAL PERMIT $ CHANGE OF INFORMATION Q i PERMANENTLY CLOSED SITE <br /> ONE ITEW 2 INTERIM PERMIT I� 4 AMFNDEo PERMIT ® B TEMPORARY SITE CL0ZVRE <br /> 1. FACILITYIS1TE INFORMATIONS,A00RESS•{MUST RE COMPLETED) <br /> DBA4RKACILITYNAME �{ NAME OF OPERATOR <br /> At7DRE88 NEAREST CROSS STREET PARCEL of(WPTI0ItAL) <br /> CITY NAME STATE ZIP 00DDE SITE PHONE S WITH AREA CODE <br /> rflPV CA <br /> 7d KFIICAT£ yL CORf'OftATI4N i INDIVIDUALG�AARTiiERSHhF O <br /> { UXAL--AGEKCY []CWMEfYJPAKV' C]STA EAGENGY' CI f .Rk�AGENCY' <br /> f1 w rw d UST N a Pubic agency,comp Wo Na 14;VOW[hg:&AMA ai SUPSNIaw of 4"Iun,paciive.&0"Im Wha oWatos tha LIST _ -- <br /> TYPE of ouSINESS C i DAS STATHION 2 DISTRIBUTOR RESERYAOIOit TANKS AT SITE E,P.A. I.D.IM(gofwnw) <br /> C] 3 A'Aku A PROCEISSCq 5 OTHER OR TAW1 LANG$ CA I'-occo S ry Wt <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY OONTACT PERSON (SECONDARY)-optbnN <br /> DAYS: NAAME(LAST.FIRST) ('31'b PHONE 0WITH AREA CODE LAYS: N4W(LAST.FIRST} r PHME i1 WrTH AREA CODE <br /> "� 7z _ l�!"!oo v/Jk,! -�7G A)IVj'S -�J•�Ci LIST „/"-C:o <br /> NIGHTS:NAME(LAST,FIRST) PHONE A WITH AREA CODE N04TS:NAM (LAST,FIRST) PHONE Y WfrH AREA OODC <br /> �11e2� tY r-ESPONStc{ib'�C�: ( <�� L1°,f-i'i! ; is <br /> 11. PROPERTY OWNER INFORMATION-JMUSTSE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CC.Y <br /> MAILING OR8TREETADORE$$ ✓ G INIOryOLAL Q LCICALdwNcy (] STATE-AGWY <br /> P LUES y E3 CCRpMTtoN PARTWA%lp 0 OMM M RCY FEDERAL49NCY <br /> GIN NAME STATE 21P CODE pHOHE i W6TFi AREA CODE <br /> VPA1E-4AWo N E :Y -3":C : <br /> III. TANK OWNER INFORMATION•(MUST DE COMPLETED) <br /> NAME Of OWNER CARE OF ADDRESS NIFDRMAATION <br /> .3`S �/ )our Al s !.Eft C,'A. ': (- <br /> MAILW4 OR STREET ADDRESS ✓ bm vp mdem ImAAt-AOENCY C]STATE AGENCY <br /> o,kjE LC.r'M.i 5 -P ZA, p COAPbRLTI[xM d PARTMitli5HIP GOUNTYJdiENCY C�FEBERLL•APsENCY <br /> CITY NAME STATE TIP CODE PHONE a WrrH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322.9669 if questions arise, <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ib�e�dkxr ULi SLf-INSURED Z GUARANTEE [1 3 RSUma E:]A WRIETYMNo <br /> S tMEROFCREDIT 1]E a on" <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notillcation and billing vAll be sfarll to the tank owner unless box I or II Is chocked. <br /> CRECYt ONE SOX INDICATM13 WHICH ABOVE ADORE$$SHOULD BE USEC FOR LEGAL NOW CATIONS ANG BILLINGS: L Q 1L= 0I-12t <br /> TN7S FORD HAS 8E8N COMPLETER UNDER PENALTY OF PERJURY,MID TO THE SES T OF AIY 0O7WLFOGE,PS TRLME ANO CORRECT <br /> OWNER'SNAME(FEINTED&S4GNEDy OWNERSTRtE; RATE MOMSTWOAYNEAR <br /> 1 ttc 741 J� <br /> <),;r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# Jt3FNDCTKXdS FAMr Yt jL1`.)} <br /> LOCATION CODE-WNONAI LNSYJ TR;ACT@-DPr*" 81JPVI80R-GISTRICT0009 -WTSC" <br /> THOS FOR M MUSI BE ACCOMPANIED BY AT LEAST(t)OR MORE PERNIIIi APPLICATION- FORD B,UIwLEB9 TH13 a A CNAI�I3E OF Sr1E 1FFORWITIQFI ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY 1MPI.UFXnNQ THE UMM('ROWND STORAGE TAW REGUt.ATM FORaX A U <br /> FORM A('M) 49 0 <br />