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�f W <br /> STATE OF CALIFORNIA x <br /> STATE WATER RESOURCES CONTROL BOARD d� e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ❑ T PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ <br /> ONE ITEM F-1 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. at <br /> FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA OR FACILITY NAME <br /> A. Teichert & Son, Inc. A.EARTeichert & Son,_ Inc.PARCEL#(OPTIONAL) <br /> NEST CROSS STREET <br /> ADDRESS —1 <br /> 103 North E Street <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME CA 95205 209-946-8580 <br /> Stockton <br /> ✓BOX ®CORPORATION 0 INDIVIDUAL O PARTNERSHIP DISTRICTS <br /> E COUNTY-AGENCY' O STATE-AGENCY' 0 FEOEAAL-AGENCY' <br /> TO WICATE <br /> 'Xow OIUSTk#pubGc#XNv.7,twnpWe tlrelorowFg ranl#d supeMwrdtlNkkn,sxtbn ord5ce xfiiN cgeMK Me UST ✓IF INDIAN #OFTANKSAT SITE I EP.A. I.D.#(apticnal) <br /> TYPEOFBUSINESS ❑ 1 GASSTATION ❑ 2 DISTRIBUTOR [1] RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR ® 5 OTHER OR TRUST LANDS 4 CAD 0 2 9 5 0 4 7 4 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Takemori George 916-386-6916 PHONEX WITH AREA CO DE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Takemori,Geor a 916-684-0813 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> A. Teichert & Son Inc. George Takemori <br /> MAILING OR STREET ADDRESS ✓ buMrG a Lj INDIVIDUAL Lj LOCAL-AGENCY 0 STATE AGENCY <br /> P-O. BOX 15002 LX CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE WITH AREA CODE <br /> CITY NAME Sacramento CA 95851 916-386-6916 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A. Teichert & Son Inc. George Takemnri <br /> MAILING OR STREET ADDRESS ✓ boxto°dicIit# = INDIVIDUAL =LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 15002 Eg CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY E3 FERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento CA 95851 916-386-6916 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 0 1 7 3 8 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓WSNmS�# 0 1 SELF-INSURED 0 2 GUARANTEE ED3INSURANCE 0 4 SURMBOND 0 5 LETTEROFCREOR 0 6 EXEMPTION O]STATE RIND <br /> ®X STATE RIND&CHIEF FINANCIAL OFFICER LETTER O#STATE RIND B CERTIFICATE OF DEPOSIT 0 16 LOCAL GOYT.MECHANISM 0 W OTHER <br /> VI. 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: I.❑ II.❑ RL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED B SIGNATURE) TANK OWNERS TITLE DATE MONTHIDAYNEAR <br /> George Takemori Project Engineer 1 12-1-98 <br /> LOML AGENCY USE ONLY J'3 16 5-5 <br /> COUNTY# JURISDICTION# —F(pA'-'CIILIITT�TY�#Y <br /> 1= 6 <br /> LOCATION CODE -OPTIONAL CENSUSTMCT# CZNAL SUPVISOR-DISTRICT ODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS T" IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORD I THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�I" f.4ORAGEI TANK REGULATIONS <br /> FORM A(6-85) �i tea/# (5VV <br />