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STATE OF CALU ORNLA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARKONLY O I NEW PERMIT ] RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PEGMR Q A AMENDED PERMIT 10� B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION b ADDRESS-(MUST BE COMPLETED) SpA <br /> DBA OR FACILITY NAME +/I NWE 01' T� ^ _ _ <br /> • /11 V 4YA'/r��. <br /> NEAR�E/Q/C/R�OSS6�6/T'F1!FFT PARGgeIDFnONAI) <br /> CITY NAME STATE <br /> CA X51+3 �V PHONE(( AREA <br /> YIG <br /> r BDA Q COPPGRATON Z-PANIDUAL Q PARTNERSNP Q LOCX-AGEMT Q COUNTY.AGENCY' Q STATEAGENCY' Q FEDERAL-AGENCY- <br /> TO INDICATE DSTRCTS <br /> '0 ,a UST A aP�C omPlne Pe+w-ng N.ma#.wNuma P.am. w woAu.Nmowma a.UST <br /> TYPE OF SVSINESS f'-1 I GAS STATION O 2 GISTRIBUTOR O RES�AMON AO F/T]M�INS AT6 SITE EP_0. 1.DJ/(n�ptbmll <br /> O T FARM {� A PROCE990R B OTHER OR TRUST LANDS O')/I� D IDA 22q 13 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PErESON (SECONDARY)-Bptional <br /> D YS. NAME(U6T.RR T) PHONE A WITH AREA OOpE DAY&MAME(LAST.FlRST) PHONE•WITH AREA CODE <br /> NIGHTS- NAME(LA5T.FIRST) PHONE N TH AREA CODE MGKM NAME(UST.RRSI) PHONE F WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION'(MUST BE COMPLETED) <br /> NAME CME DF AOORESU INFORMATiDN <br /> 69 %FebL�je_ <br /> MAILING OR STREETADJp-RESS•• Lermwous. [7 LOCALAGETNCY Q STATE AGENCY <br /> Z L/ I�1 i V Q CORPOMTON Q PAN NFABHP =CGUNIY.ALFNCY Q FEDERAL-AGENCY <br /> CITY NAME M1M1//._ I - 9TATE- ZIP GORE O 'H• RH�ijEAC GE <br /> •N•--•rIF.PJVI N//.rel G7^ Yro fl <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O WNSA CME OF ADDRESS INFORWITION <br /> MAILING OR STREET ADDRESS ✓ OPFY e Q NDHGLIAL O LDGL'MGeNCY Q BTATE-AGENCY <br /> C3 COW(RATNIN Q FARTNERSHP []COV`M'AGFNCY Q FEDERa WENCY <br /> GTY NAME STATE ZIP CODE PHONE F PATH MEA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCpIjNT NUMBER-Call(916)322.96691 questions arise. <br /> TY(TK) HO 4 4- -� /�/;- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> r�.•MdI. 0 1 BELF-WRED 2 oUAA.NTEE O a 1NSIMACE O A WRETYBOND Q B LETTEAOFCRW O B 0111FIM Q 7 STATEFUNU <br /> p#STATE NIA a CHIEF FINANCIAL OFRCER LETTS 01 sTATE NIAac9ATFIFATEOF DEPOSIT Ota ICCAGOVT,MELIMM7N 0 "OTwv% <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal Rotlticdon eW billing WE be sent to the tank owner unless box I or�r 1-1 its checked. <br /> CHECK ONE BOA INGCATIN(T WHICH ABOVE ADDRESS SHOULD M USED FOR LEGAL NOTIFICATIONS AND BILLING, IF <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TCI THE BEST OF MY KNOYVLEDGE,IS TRUE AND CORRECT <br /> T.N� NAM£IPPINTEO B S�A EI 1 TANK O�W"NE��R��S T�ITLE// DATE ?NIDAY/YEM <br /> M SAA //// c., (//�o/ 9 <br /> LOCAL AGENCY USE ONLY ��/�F n <br /> COUNTY P JURISDICTION• FACILITY• <br /> LOCATION COOS •OPT IO NAL CENSUS TRACTI-OPTIONAL I6Uw{SOf1D15TPICTCODE - <br /> 7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION-FORM B.UNLESS THIS IS A CHANGE OF SITE NEFORMAT70N ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS '^ <br /> FORM w(4931 i' (((���}}}="' �# <br /> lU e <br /> lC°��((hQ 5S ,� (� <br />