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Si1TECFC.iL:FCFNA ���- • _ <br /> WATER RESOURCES CONTROL BOARD +� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORT A -0 gra <br /> y e' <br /> °•L.., <br /> COMP THIS FORM FO EACH FAC.LITY;SITE <br /> MARK ONLY L_ I NEW PERMIT e. PE,. T S CHANGE OF INFCnMTICN � 7 PERMANENTLY CLOSED - <br /> CNE ITEM ! 2 :NTEA,m IT t_ ♦ AMENDED a_ NIT 1 S TEMPORARY SITE CLOSURE <br /> I. FACILITYiSITE INFO ATION 3, ADDRESS-(MUST BE COMPL D) <br /> OdA CR FK'.uTY NAME JE CPEAATOR <br /> AGGRESSONCRCSSSTREET I PARCELA(CPCXINAU <br /> C:TY.NA`:e I STA Zr CODESITE PHONE s WITH AREA G^•CE <br /> ✓ 3Cx A <br /> TOMOCATE ,_.CCRPCRAT:CN 0;NIXYOUAL 4 PASTNEAW 0.U .ATS OERCy Q COUIRY.AOEyIy <br /> [_, STATE-AGENCY C_ FeERµ_+.(`eNCY <br /> TYPECF 3LSINESS �� L S STATION l- 2 OLS-.;1;2U-.CA ✓ F-NO1AN 1 OF TANKS AT SITE E.P.A. L 0.1(cotarm) <br /> RESUESATV ATIC <br /> NON n <br /> {1 7 FA I—; A PROCESSOR S OTHER OR TRAVCS a // <br /> EMERGENCY CONTA _. {PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME{LAST,FIRST) PHONE A'WITH AREA CODE DAYS: NAME tLAST.FIRST) <br /> ====:E:NIGHTS: NAME(uST,FIR$' PHONE IWITH AREA CODE NIGHTS: NANE(LAST,FIRST) <br /> Eun ee• Rae r^re <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED) <br /> NAME CARE OF ADDRESS AFORMArICN <br /> MAILING CR STREET ADDRESS ✓ yA RAaryA <br /> L-1 INMCUAL 0 LOCAL.ACENCY 0 3TAr.AGEVCY <br /> 11 CCRPCRATION = PARTNERSHP `r„ coufm.AGERcY 0 FT`EFAWGNCY <br /> CIrY NAME I STATE I LP CODE I PHONE I WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .MAILING CA STR ET ADDRESS ✓ Ms1loI,I16 0 MVMAL L._1 LOCAL4G;NCY 0 STATE.AGENCY <br /> Q CoRPoRATgN 0 PARrIEILSMP 0 omwm.%Gs-vY 0 FEuE A4G,?CY <br /> CITY HANE I STATE ILP COOS ilIDNE a PATH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE; FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> 44 <br /> TY(TK) HQ -L L I I I 1 1 <br /> ' <br /> V. PETROLEUM UST FINANCIAL RESPONSiBIUTY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓eAA r.Nra 0 I rwc4i REO L_J L QMRANCEE 0 1 mum" 0 A WRVY BOxO <br /> C S LETTER CFCRECIT Q a Oniwrcm 0 as OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notiTN�tion and b1Gng will be sent t0 the tank er unless box�*Ntr 11 is ched ed. <br /> CHECK ONE BOX AOICATM WHICH ASOVE ADDRESS SHOULD aE USED FOR LEGAL NOTFICATIONS AND S4LNCL. L = IIL <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE 8ES7*OF MY KJVOWLE6qE,IS TR O CORRECT <br /> APPUGAVrs NAME tPRWrEO A SIGNATURE) APPL.CANTS TITLE DATE MONTWDAYIYEAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISOICTCN a FAC:LrrY 1 <br /> [35 �N/�Y'fi7� <br /> LOCATION CODE .OPTIONAL (CENSUS TRACT$ .QPTICNAL I SUPVtSOA•DISTRICT COOS •OPTIONAL <br /> THIS FCRM IAUST BE ACCOMPANIED BY AT LEAST(1)OR!ACRE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORK A(Nt) <br />