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SEP 07 'SS 14:12 FROM;[ C E S T-619 P 06/06 F-248 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD A A'd• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> COMPLETE THIS FORM FOR EACH FACRRYlSITE <br /> MARK ONLY Ft T NEW PERMIT Q S RENEWAL PERMIT 5 CHANGE of INFORMATION ij 7 PERMANOSE0 a) <br /> ONE ITEM ED 7 INTERW PBRFAT Q ! AMENDED PERAPT S TEMPORARY SITE CLOSURE 7 j <br /> I. FACIL ITYISITE INFORMATION d ADDRESS-(MUST BE COMPLETED) <br /> HAM,OF OPERATOR <br /> °� F ACILIT� TrAckln �➢el�a�� e✓ fACI�I� icevin Basso <br /> ADDRESS NEAREST CROSS STREET PAPCAI roPTgFMII <br /> 401 SoN}H Lincoln sI . tNMrcH S+. <br /> CrInr tow STATE ZIP CODE SITE PHONE F WITH AREA CODE <br /> StOCL> oh CA 204-4vv-5111- <br /> ✓BOX jjdtpO.TOM (]/AXVOVAI p PARTHEIOKIP p��S eCY C]Caxm.WFl+er' O STATE-AGENcr' [�1fDfR&-AGENCY' <br /> TO INDICATE <br /> Aarr 0 LIST Y P PAA WM.P Aft b bb'*T�d NmPr'QPrd S k' eema db AUN SPAM"W UST <br /> riPE DF InIGINGim p I D MATO, D e -I IRITOR I I3 RESERVA°0 i OF TANKS AT SITE E-P.A I.D./(00P 0) <br /> O S FMM 0 A PROCESSOR Gt e OMER I OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PAWRY) EMERGENCY CONTACT PERSON (SECONDARY)-optloml <br /> DAYS, NAME(LAST`FIIRST) RHONE I YRTH MEA COOS DAYS' NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> 54SSD 1tC:JIn Z0AI-LL41A-S1112- <br /> NIGG T6: NAME MST.FIRST) PHONE I WITH AREA CODE NrKT6'. NAME(LAST.FIRST) PHONE 1 WITH AREA CODE <br /> Basso ICev, n 1..01 -4!,v- talk <br /> H, PROPERTY OWNER INFORMATION-(MUST 86 COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAM <br /> I�eVln SAsso <br /> MULINGOR67REETADORE661r owvM p NONIDUAI, p LO 49ACY p STATE-AGENCY <br /> 11145 W. c H 4V�w W A lYJ COWMTIGN p PAMERLw M COUNly-M Y p Fca6Rw/ID/CY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA COVE <br /> S} ock� oh G1. 95z0v zo9 -4��-51� z <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE of ADOPESS INFpRMATIDN <br /> (CGJIn BAI SS <br /> MAILING OR STREET Aoo�s9 r w•nMI pWNwu OLGGN.ADENCT pmATEAOeNCT <br /> C_7 H.1 rT'c r W Al C1�c�RPORDroN [7 PAATHEPSHw O CWMY•AoFNn p FEDRwAGENCY <br /> CRY E MATE ZIP COLD P1gMGI VAT,AR"=`e <br /> Sfiock�ah CA I gSZol/ fv-5117— <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> Tr(TK) HQ 4 4 - <br /> V. PETROLRU f UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> r muvdt.w T EOFPWDIFD (]71HMPNnEE p 7 gAUPArtE p!WPNMWW p E LETTEAOFCNEDIT 0 E EXEMPTION p 7 STATEFLwD <br /> pf reeftwlonEsrA«+Ia.LOTsaeRlcTTw p.aATewNo+anTmrcATeoroEPocn CDTOLOC&WVT.MEUANSM =1NOWES <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS L09W notification and bllGng will be sent to the lank owner unless box I or II is Checked. <br /> CHECK ONE BOX INMAT04 WHICH ABOVE ADDRESS SHOULD Be USED FOR LED&NOTIFICATIONS AND BILLING I.Ej 0.[= IR.� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDOE,15 TRUE AND CORRECT <br /> TANX OWNER'S NAME(PRINTEOAML OWNERS TLM LATE MpNT1IDAYlYCM <br /> kcVTVI 14sso ovJnC✓ <br /> LOCAL AGENCY USE ONLY <br /> COUlm I JVPo90IC'TWH P FAC4ITY I <br /> LOCATION Coot•UPTOP44 cEN6Ue TRACT F.OFITONAL 7 <br /> U7 <br /> -DISTRICT CODE-OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST n)OR MORE PEW APPLICATION•FORM B,UNLESS THIS S A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE TNM FORM WITH TME LOCAL AGENCY IMPLEMENTING TMa UNDERGROUND STORAOE TANK REGULATIONS <br /> iDImAA(E.%1 <br />