Laserfiche WebLink
STATE OF CALWOMmA ' <br /> STATE WATER RJ=tM=C=TRGL BOMDOle <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> COMPLETE THIS FOO FOR EACR FACTL"ISITE .ORM* <br /> MAFN�way { NEW PFRMR S PIMWAL PEMMT 6 CHAMBE OF OWOR MATION 7 PERMANENTLY CLO EU S E <br /> ONE trEY In s INTEAIM PE;Wrt 4 AMENDED PERMIT © 9 TUMIORARY SITE OLASURE all <br /> L FACILIlY/S[TE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DOA 09 FAOILITY NAME NAME OF OPERATOR <br /> Iftawal s1e11 <br /> ADORERS NEAREST CROSS STREET PNTGEL M i0araauy <br /> CITYNAM6; STCA Z17 ]tiY-9fitSE t7J AREA CODE <br /> T Io w�TE iftCOVOM1101d ED XYoMUAL p PMTNMW E3 Lau4,aKW'1 p aaxm. Her d stAz>AGENCY Cl L Frlor- <br /> it omw d UST Is a puble rrpar,Wy.aamPlr■"fpllpwr;:p4LTN ed St"mbpr d dMeioR ppkb Ar aX.T„MdeL aP.glas the UST <br /> TYPE OF BUSIHESR t CAS STATION S DSTFINWOR Is TANKS A7 SITE 6,P.A. L Q 0 ! <br /> e FARM -4PROCEB80R Co b OTHER RESERYAYION <br /> 0R 7ffiXT LANDS I CA0951460115 <br /> EMERGENCY CONTACT PMWN IPRMARY) EMERGENCY CONTACT PERSON (SFCMARY)-Wlaww <br /> DAYS: OAST.FIR PHONE a VATH AAEA Oom DAYS:� NAME(LAST.FETSTI PWONE a wmi AREA COM <br /> arroli 1tS-361-3755 Aastio ft as 109-365-3755 <br /> NIONTS:NAME iLAST.F(Rn PH"0 WThi AREA 000ENIGHTS:NAME(LAST.FIST') fMOME 41 VNH AREA CODE <br /> Rai Carroll 19-457-6611 Alstie raters 104-63?-7618 <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAW HILL OIL COIFAIT <br /> MAILING OR STREET A4DA fe- ✓in to wiliFe 0 m mural. C3=k Aawcr p STAT14AMNO <br /> F.O. B91 4013 IM Qvft uT" C3PABTNE3ISFpP M COIINTY•AeEM07 Co FMPALAGEMEY <br /> My NAMP RTAT$ w C PHONE•WTTH AREA CON <br /> mmil 94124 <br /> EL TANK OWNER INFORMATION-(MUST BE COMPLErgV) - <br /> NAK aF OWIER CARE OF ADDRESS INFORMATION <br /> 8= OIL CO><Pim H,B, i H IHPHH lIITIVH <br /> MAILNOI�f{MTREETADDREss ✓hollnlllllaAs [Z]MCMAL d Look4 ew Q ST1tTE-ATEMG9 <br /> MINATIDN a © MR <br /> MMUSIMP GWWfY.AW= C3 rMI ,0.tll®F.tICY <br /> Guy NAME d Cot;TATE >JP OopE M WITH AREA CSE <br /> cocall CA, 04514 -- 1 U"75-6300 <br /> IV.BOARD OF EQUALIZATION UST STORAGB FEE ACCOUNT NUMBER-Ger(916)322-NN l quesilom Brise. <br /> TY M Ho 4 W-1- o o 7 <br /> V. PETROLEUM UST FWAMAL RESPONSIBIL[flf•(MUBT BE COMPLETED)-IDENTIFY THE MT`TfMODM USED <br /> ✓or.M1Mr� SaRmw J a gtmLv 1iE a s mouRoct ©A WF ETT MW <br /> C:l E W=011 C. d a E7mrP M a amm_ <br /> VL LEGAL NOTWICAJION AID SNJM ADDRES . L"d nct5eati(n and b ilk ba sent b the Ta*comer wim boor I or N b ehoemd. <br /> offir O 0 aOx NDICATMKa IIVHM ASOYE'Aim' A R!SNOTAD 6E umo FOR LWALNUTpr-cTDMS AND alLLMIN L d La rL Ej <br /> 7W FOPMHMaEFEN ,E7FD PEhi4LTyOFPEI4MY,AAV TOTJEBUT OFAlYWM%Ee",lBTRLeANUC MWCT <br /> OIAMIE IIASAE . ... OWNERS <br /> GATE MDMrUipAY1YFJW <br /> LOCM-AGENCY U=ONLY <br /> CCKJNTY#. JURISDICTION! FACILITV S <br /> EM <br /> LOCA7DMCOGE-QPTA7nIEt. Ol1y8lJBmv=f-CFTC"% 81JPIfMUM-OIgTIM:fCObP.- <br /> TM MMMl=KAC=WAMM BY ATLEASr(l)tlRM0REPfiRMffNftWM. FOFOA Br tKM TW 19 A 01ANX IDF STYE WaRMi9=ONLY. t <br /> FORA A P" OW M M MW FILE THIS FOTTYrIM fOCX AfiMCY WLF.AEWM THE MRMMC:ROM TTIQIOTANIT Ftt<GULJITy M MMOa <br /> L00/ZDDo 'IID lilaHs OCT92L90TS TD'S TIT:TT 26/9T/T0 <br />