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STATE OF CALIFORNIA r U` r <br /> STATE WATER RESOURCES CONTROL BOARD e+ <br /> UNDERGROUND S*ronAGE TANK PERMIT APPLICATION FORM A WJIM <br /> � a� <br /> OOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RFTJI tVAI PFllt.slF j 5 CHANGE OF INFORMATIONrr 7 PERMANENTLY CLOSED SITE <br /> FNII <br /> ONE ITEM _ 2 INTERIM PERMIT f I A AM (; I'{HMIs k'(8 TEMPORARY <br /> SITE CLOSIJAE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> 00A OR FACILaV NAME <br /> f• A NJ <br /> 1 NAMFOFOPERArOR <br /> ADI.RF,.,; - ----- � C -I1J <br /> c � /' � �Zitb <br /> NF.ARFSTC:FlOSSSTAEET PARCELO(OPTIONAL)— -` <br /> CITY NAME V - -. <br /> - <br /> STA ZIP COUE <br /> SITE PHONE R WI AREA GODS <br /> ✓ anx _ ,/ - , <br /> �f CA. S-.ZP .L3 6 <br /> TOINTNCAIF C. CORPORATION f 'J INDIVIDttAI f I PARTNFRSII(P I I LOCAL AGENCY COUNTY-AGENCY <br /> ___ DIS4RN;iS 0 STATE-AGENCY F-]FEOERAL-AGENCY <br /> IF <br /> TYPE OF BUSINESS 1 GAS STAT40N j _j 2 DISTRII;0It?Il ! I .r IIF INpIAW A OF TANKS AT SITE E.P.A. L D.K(opTimatJ <br /> ( ] 3 FARM a PRCM;ES9c�A 5 OTHER FIFSE f)RTAUST LANDS <br /> _ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> -54—'s NAME'fl✓1ST,FIRST `---"� `.^-----_. <br /> 1 PHONE r WIII I Aft}A I;a�lx DAYS• NAME(I AST,FIRST) <br /> p1GI4I; NAMET LAST,FIRS <br /> � �yIIPIlONFx IFIInRFACr�)IT/F' NIG 31 NAM EILASTI,FIRST) R pufO/N,E�t7 LTH AREA CODE—PHONEi WITH <br /> _-.--- <br /> C—1114 <br /> _II. PROPERTY OWNER INFORMATION MUST BE COMPLETED) <br /> rt T 1LI IFCAIIFOFATI)glINFORMATION. <br /> r)R IFIFFTADDRERS Mels irMira3a! 4, F- y"�" '� (�-jy STATE-AGENCY <br /> r,�- � I NDIYIDUAL n L(1CAlAGfNGY1"IIY Tan Aa: -`""'_.— _ - 1r(If;Iti�RhfiCIN I,] PARTNERSHIP -- <br /> E -..-.— ____�_�.... ___ L_j COUNTY-AGENCY [a] FEDERAV.AGfNGY <br /> $TAI-E 21P CODE PHONE a WITH AREA CODE <br /> III• TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> r:Ar,fil <br /> OF l , ,, • CAAF r>F ADDRESS INFORMATION <br /> 111irlr;OR Af?d7RES5 <br /> lr �� � ✓ Mx bi Nlr�le I— NDNIDUAL LOCAL-AGENCY U <br /> L. STATE AGETtGY <br /> ('UY NAME -- I CORPORATION —(�J PARTNERSHIP D COUNTY-AGENCY ®FEDERAL-AGENCY <br /> STAT F ZIP CODE PHONE s WITH AREA CODE <br /> �—_-- LV- 0JagjMUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> 011 <br /> ^� �. . <br /> -k i) USED <br /> I )NI$NVTF 10 LEGAL TEN vCR 'l <br /> '.. <br /> •' FOR ALL DEBTS.PU �. •��.,... <br /> euc AND valvArF [ J A SURETY BONtl <br /> ���:, D 1414 2 8 71 <br /> d 4 <br /> Ss be x 1 Dr II' Checked. <br /> - <br /> k` IIL <br /> �, •I. I' <br /> a <br /> UE AND I] <br /> D 1 ���R��T <br /> 4I <br /> MDNT <br /> ,. H/0AYIVEAR <br /> - i+•arMtlfseM.NSY,efw J <br /> "' �: .• ' t"r <br /> (41I-,]NAI ACL-NSLISTRACTN 01-N.'NAI ,'iIjl'VISOR-DISTRICT CODE -OPTf&w - --- <br /> al GS F OHM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORF PFRMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FILE THIS FORM WITH THE LOCAI.AGENCY 14111LFMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FI�f1n017A RF 31 <br />