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a <br /> STATE OF CAUFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITIE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Electronic Si n Corp.Z DBA AD ART Electronic Sign Corp. / DBA Ad Art <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTONAL) <br /> 3133 N. Ad Art Rd. Cherokee Rd. <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> Stockton CA 95215 209-931-0860 <br /> .1 Box <br /> TO INDICATE [M CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY- O FEDERALAWNCY' <br /> •ff owner of UST lea Pubic DISTRICTS' <br /> Iw agency,camplge the following:name q Supervkar q dHiebn,section,w office which operalec the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIANa OF TANKS AT SITE E.P.A. I.D.S(gNronal) <br /> 0 3 FARM Q 4 PROCESSOR ® RESERVATION <br /> S OTHER ORTRUSTLANDS 2 CAD-982060634 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> hanle Lorin 209-931-0860 Williamson,Rand 209-931-0860 <br /> NIGHTS:NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Shanley,Lorin 209-956-6926 Williamson,Rand 209-772-1004 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Lou A. Pa ais <br /> MAILING OR STREET ADDRESS ✓ box bIrdbW 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. BOX 8570 QZ CORPORA TICK O PARTNERSHIP 0 COUNTYAGENCY 0 FFDERALAMI CY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Stockton CA 95208 209-931-0860 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ad Art Inc. Mr. Lou A. Papais <br /> MAILING OR STREET ADDRESS ✓ I'm ts;W O INDIVIDUAL 0 LOCAL AGENCY E-1 STATE-AGENCY <br /> P.O. BOX 8570 CORPORATION 0 PARTNERSHIP O p COpCOUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAMEStockton STCA ATE r95YO8 LV _751ARURb <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY®K HQ M44- - O 2 5 0 0 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Lot blNkge 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION [-1 PG OTHER <br /> V1. 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: 1.111 IL E] III. <br /> THI ORM HAS BE COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWN S RINTED&SI E OWNER'S TITLE DATE MON YN <br /> ou r PAs <br /> LOCAL AGENCY USEDNLt <br /> COUNTY It JURISDICTION It FACILITY* <br /> FTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTVAI& <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3W) FORD033AJI7 <br />