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' • STATE OF CALIFORNIA � ^+ � <br /> STATE WATER RESOURCES CONTROL BOARD 3• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :�� �e <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE °.x,.°��• <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ® d AMENDED PERMIT O 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAORF CILITY NAME NTE OF OPERATOR <br /> Jac�Cpot Food Mart on Haywood <br /> ADDRESS NEAREST CROSS STREET PARCEL%OPTIONAL) <br /> 14000 E. Hwy. 88 Elliot St. <br /> CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA COOE <br /> Lockeford CA 95237 209 727-5442 <br /> TO INDICATE ®CORPORATION = INDIVIDUAL = PARTNERSHIP =LOCAL-AGENCY = COUNTY-AGENCY =STATE-AGENCY = FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION IF INDDIAN %OF TAA 3S AT SITE E.P.A. L D.%(aPNmal) <br /> O 3 FARM O A PROCESSOR O 5 OTHER OR TRUST LANDS <br /> • <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> Haywood Rand (209) 727-5442 Adams, Brad (916) 399-0820 <br /> NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> I] <br /> v <br /> Haywood, Rand 209 763-5818 Same Same <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Timp nil CC- Inara Rogainis <br /> MAILING OR STREET ADDRESS ✓ box bindlcaN = INDIVIDUAL = LOCAL-AGENCY = STATE-AGENCY <br /> P.O. Box 24447, Terminal Station XJ CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> Seattle, WA 98124-2447 WA 98124-2447 (206) 285-2400 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) y <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Time Oil Co. Joseph G. Sanzo <br /> MAILING OR STREET ADDRESS ✓ box binkab = INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> P.O. Box 24447, Terminal Station INCORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 9111D P IT A <br /> Seattle WA 94-2447 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4f41_1 0 1 114 13 17 19 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.® H.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PE Q�PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 5 SIGNA ) APPLICANTS TITLE GATE MONTWDAYNEAR <br /> J. Michael Paisley UST Specialist 8/19/91 <br /> LOCAL AGENCY USE 0 <br /> COUNTY# JURISDICTION# FACILITY# n <br /> ff I I I/ KF5vD� / �� <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-DISTBICT CODE -OPTIONAL <br /> 17 Z3.St-2 ?.c) <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(490) FOR0033AA2 <br /> 6 <br />