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STATE CFCAL;FCRNUA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR%11 A <br /> COMPLETE THIS FORM FOR EACH FACILrTYiSITE <br /> .NARK ONLY l 1 NEW PERMIT 7 RENEWAL PERMIT �': CHA F 4 ON 7 PERMANENTLY CLO <br /> CNE ITEM 1 II 2 .INTERIM PERMIT II- A AMENDED PERMIT ITE U <br /> I. FACILITY,'SITE INFORMATION & ADDRESS•(MUST BE COMPLETE' <br /> CBA O B PACILITY NAME ,NAME DF OPERATOR <br /> G-R- 5 0-- N1r , FF_FG �6i/ /��r/c,�_ <br /> ACCRESS NEARESTCROSSSTREET PARCELAiCPTONAU <br /> CITY VA:•c^ STATE ZIP CODE I J SITE PHONE.WITH AREA CODE <br /> ✓ SCX <br /> - I CA b <br /> TOADCATE r'CORPORAnoN p INorviouAL 'Q PA'RTNERSHP p LOCA AGEVCY p CCUNTY.AGENCY p STATE-AGENCY p FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF 3USINESS I GAS STATION = 2 OISTRIaUTOR �'�, RE✓ IF INOIAN a OF TANKS AT SITE 'c.P.A. L 0..(mnmaq <br /> ^ N <br /> :ARM A PROCESSOR J 5 OTHER OR SE RVATICTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRSA PHONE S WITH AREA CODE NIGFITS: NAME(LAST,FIRST) <br /> PV �• TM R� ^K <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME j 11--�A Q �S //.. /- \/D- GRE Of ADDRESS INFORMATION <br /> W If <br /> .MAILING OR STREETAOCRESS W.E� p INDIVIDUAL Q LOCAL-AGENCY p STATE AGENCY <br /> C CORPORATION p PARTNERSHIP p COUNTY.AGE,,CY `; FECERAL.AGENCY <br /> CITY NAME STATE I ZIP CCCE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER A, <br /> S A 1A v as aY;0r— 71f <br /> ATI <br /> MAILING CR STREET ADDRESSn INDIVIDUAL p LOCA-AGENCY p STATE-AGENCY <br /> J CORPORATION p PARTNERSHP p COUNTY.AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP COCE PHONE P WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - I I I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ EAt a YNFeaM I SELF-INSURED i 2 GUARANTEE Q 2 INSURANCE Q a SURETY BOND <br /> C 5 LETTER CF CREDIT p 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal ratification and billing will be sent to the lank owner unless bG f or II is checked. <br /> CHECKONE BOX NOICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL UL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL,CANTS NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MCNTWOAY/YEAA <br /> LOCAL AGENCY USE ONLY w� <br /> C�OUNTTY IF JURISDICTION X FA ' a <br /> I-•/-L-L-I <br /> LOCATION C -Qo170NAL CENSUS TRACTA . NAL ISUPVISOR-D TRIOT CODE -CPT/ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION•-FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> FCR0W0A-S <br />