Laserfiche WebLink
STATE OF CAUFDCJGA <br /> '-§iATE WATER RESOURCES CONTROL BOARD " jCB•'vy'tr+ \: <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> &CMPLUETHIS FORM FO EACH FACLITY:sfTE <br /> ,NARK ONLY L— I NEW PE. IT _ c PEn T S CHANG-c OF $NFCRYATICN ;_ J PCAMANENTLY CLOSE) <br /> CNE ITEM 2 :NT=i, IT a AMENDED P�AiMIT 6 �cMPORARY ST CICSUR'c <br /> I. FAC1L(TYISITE INFOP4TION 3 ADDRESS•(MUST BE COMPL I IOD) <br /> �dA;;R:+C:uTI NAME <br /> NAME OF CPE:ATOR <br /> AGGRESSNE EST CRCSS STREET <br /> o . l✓ N <br /> .Y NA-4 j ) STArESITE PHONE.WITH AREA CCCE <br /> , lrAZIP CCCEl 6i <br /> TOIMDC+TE -T�G:RICRACON C �NOIVCWP VAL PARTME;L L_IDCAL-AGENCY C COUNrYJOEYCY C STATE AGENCY C FFCERAAGEMCY <br /> �\ DISTRICTS <br /> TYPE CG 3USINESS rGAS STATION C 2 OLSTA:aUTCA = ., F INOAN -OF LINKS AT SITE E.P.A. L 0./ICRI�yI <br /> RESERVATICN <br /> 3 FARM rA PgCC'cSSCR S OTHE <br /> -- R OR TRUST LANDS <br /> EMERGENCY CONT CT79-%0 PRNAAY)J EMERGENCY CONTACT PERSON (SECONDARY)•opdwal <br /> GAYS:NAME(LAST,FIRST) PHONE a WITH AREA COCE DAYS: NAME(UST.FIRST) <br /> e <br /> NIGHTS:NAME(LAST.FIRST) PHONE.WITH AREA CCOE NGHTS: NAME(LAST.FIRST) <br /> e c.yATV A9CA r^/Re <br /> B. PROPERTY OWNER INFORMATION• UST BE COMPLETED) <br /> NAME n I CARE OF AOCRESS INFORMATION <br /> NA;L>.G OR STREET AOCRE'PS i ,� ANammoi C PIOIVOUA C LOCA-AGENCY C STa i•AOENC9 <br /> C CORPORATION C PMSTMSSHF C COUNTYIGE.MCY C T-.CEPALL+G'cNCY <br /> CITY.NAME I STAIe I ZIP COCE I PHCNE a WITH AREA CCCE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ACOAESS WFOAMA-,.CN <br /> MAANG CR STREET ADDRESS ./ =N.oFa. <br /> C uavouA C LCCAUAGFOKT `; r+r.AGENcr <br /> C CORPCRATION C PARTMAILSP G'1 COUN YAr;-,Cr FIR)PA46EICY <br /> CITY NAME I STATE I ZIP Coo I PHONE•WITH AREA COLE <br /> IV.BOARD OF EQUALIZATION UST STORAGE; FEE ACCOUNT NUMBER•Call(910)323.9555 it ques5ons arise. <br /> 4 <br /> TY(TK) HO 4 I I II I I 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELLASURED C 2 GUAA.WTEE C I MSUAMCE .'I;] A WREN iONO <br /> C S:FTER Cc CAEOT ICS DmwwN C BS O <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank Aarvn s r <br /> CHECK ONE BOX WCCATI G WHICH ABOVE ACCRESS SHOULO aE USED FOR LEGAL NOTIFCATIONS AND BaLNG <br /> THIS FORM HAS BEEN COMPLE ED UNDER PENALTY OF PEFUURY,AND TO THE BEST OF AIY KNOWLEDGE,IS TRUE-WD CORRECT <br /> APPLICANTS NAME(PRWio7 A SIGNATURE) APPLICANTS TITLE ` MCNTWOAYNEAA <br /> -7'-,4L//0,) 9 3- <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACYTTY a <br /> Ez � 7� CID 00 /161 <br /> LCCATICNCCACE -CPTION4 (CENSUS TRACTa -OPTIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FCRIPAUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANCE'OF SITE INFORMATION CNLY. <br /> FORM At131) FCR=S $ <br />