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Sent ray: nnL utaiuly anvur; /U//Ei�titl 5; reo-3-99 10:55AM; Page 114 <br /> STATE OF CALIF MA <br /> STATE WATER REBOUBUCES CONTROL BOARD :��, <br /> 'UNDERGROUND STORAGE TANK PERMIT APPUCATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILU 191 '�.� „„.. <br /> MARK ONLY 171 N�.W PERMIT F-13 RENEWAL PERMIT ® 6 cmANG6 OF INFORMATION 7 PERMANENTLY CLOSED.917E <br /> ONE ITEM ❑ 2 IN''PRIM ® 4 AMENS PERMIT O I TEMPORARY SITE cLosum <br /> 1. FACILITY/SITE INFORMATION A ADDRESS-(MUST BE COMPLETED) <br /> oeAa FieeaaT Sbe�Il Au9j?p ara <br /> ADDRESS _...__ ._._ NEAREST CROSS STREET PAAM®(OPTIONA) <br /> 880 Victor load Ilickau Road _ <br /> CITY NAME STATE XIP CODE SITE PHONE M WITH AREA CODE <br /> Lodi CA 1 95240 209-368-3155 <br /> ✓6DX j4i11RPW-10N C pVpMA ®PARTRFTi9iIP Q LOGur GWY Q COWY.ApT=' Cl STATE-AeEICY- Q 1;WFR&,QENCY° <br /> TOI CXM omr=s <br /> •AtrenaorUBTISApIMe ®4» rem.a - amvban,�m+a�eewAo9lo�eltmlreU6T <br /> TYPE OF BUSINESS fZ I GAS iTATION ❑ 2 DISTRIaUTOR ® <br /> ® ✓IF INDIAN I OFTANKSr SITE EPi.t�a4?t•�fr, ' <br /> � <br /> FARM 4 PROCEOR ED S OTHER OR•RUSrl g <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-coonat <br /> DAYS:NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS:NAME(LAST.MRST) PHONE R WITH AREA CODE <br /> TrACY ossbar. 101-361-1731 ha ti 209-368-3155 <br /> NIGHTS; NAME(LAST.FIRST) PHONE R WITH AREA COM NK3NTg NAME(LAST.FIRST) PHONE•WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 191111,011 UTI1RFRISES, LLC WE Mattis <br /> mAILwO OR STREET ADORESS ✓ ®msb p WNIMAL 0 LWA4aacy ©STAT&AGE CT <br /> P.O. 301 8080 ®COMWATIM 0 PARINMKIP C.]C0UNTY4WV( p FEDEUf.-M84CY <br /> CITY NAME STATE ZIP CODE PHONE R VWTH AREA CODE <br /> 11,111119Z I <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> E UILOB SI PI)BIS, LC lura Mauls <br /> MMLINGORSMEETADDRESS ✓ babbAOeb ©AOpmx O ISICALA.MY ©sTAT&•Acp= <br /> CWWTION p PAITIMM P p COIMYAGENCY p ROERA•AORM <br /> CITY NAME SPATE ZIP CODE ON <br /> 111:1111 Rills <br /> IV.BOARD OF EQUALIZA71ON USI'STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 U questions arise. <br /> TY(TK) HQ ®- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPL D)—IDENTIFY THE METHODS) USED <br /> ✓,�a„ I saF ®I (=2111SLAW00 04010FIETYMM ©s LETTER of ORBIT 0 6 M MM” f::j T 6TAM RJND <br /> ZIssrArERms"ArFrVINCIALOPPICINIINIM EDISTAWIRMACMIRIX110FORPOSIT 1=310 LOCAL PDYr. 099 OTTANI <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notificadon and biting Win be sent to the tank Omer unless box I or Il Is chadced. <br /> CHECK ONE BOX MOCATING WHICH 5-sOYN AOOPIESS SHOULD BE USED POR LEGAL NO'T81CAT WM AND SKIM 1.❑ 11.❑ III. <br /> THIS FORM HAS BEEN C r AtFV D UYVDER PENALTY Of 00WRY,AND 7.0 THEOESTOFMY KNOWLEDGE,IS T AILIE AND CORRECT <br /> TANK OWNERS NAME(P'0'SNTED 6 SK`: ATUFIM TANK OWNERS 717M DATE MOHtt�WarNO AR <br /> LOCAL AGENCY USE ONL° <br /> .w, <br /> COUNTY N JURISDICTUON 1 FACILITY N <br /> t.-.J..-.J I l __l—Li I I <br /> LOCATION CODE-OPT MAL CENSUS TRACT I •OPTIO M SUIM9OR-msTRICr COOS-OPT KINAL <br /> THIS FORM MUST BE ACCOW-VED BY AT LEAST(1)OR MOM PERMIT APPLICATION-FORM B.UNLESS THIS tS A CHANGE OF BRE INIFORMATION ONLY. <br /> OWNER MUST t Tests FORM WON THE LOCAL AGENCY jMpLgME;t TtNG M UNMGMUMD STORAGE TANK REGULATTONS <br /> FORM A <br />