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STATE OF CAUFORWA avc? <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILrTYISTTE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT a CHANGE OF INFORMATION [:] T PERMANENTLY CLO <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Stockton Shop A. Teichert & Son, Inc. <br /> ADDRESS NEuARESTCROSS STREET PARCELO(OPf <br /> 103 North E Street Weber 153-18 -1 <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> Stockton CA 95205 209-946-8580 <br /> T.1 Box <br /> xTE IBI CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDENALAGENCY' <br /> DISTRICTS' <br /> •N arner AI UST ie a public agency,cortplele the folming:name of Supervkor of division.sec ion,or Mica which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION0 2 DISTRIBUTOR I� RE/ IF INDIANATION <br /> a OF TANKS AT SITE E.P.A. I.D.i(apranall <br /> Q 3 FARM O A PROCESSOR ® a OTHER ORTRUSTLANDS CAD029504743 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Broaddus Russ 209-946-8580 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> Takemori George 916-684- <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A. Teichert & Son, Inc. George Takemori <br /> MAILING OR STREET ADDRESS �y✓�box badICAN 0INDIVIIUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. BOX 15002 [X]CORPORATION 0 PARTNEUTSHP 0 COUNTYAWNCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE 51 PHONE a WITH AREA CODE <br /> Sacramento CA 958916-386-6916 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Same as Property Owner Information <br /> MAILING OR STREET ADDRESS ✓Oos binsleals O INDIVIDUAL 0 LOCAL-ACENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONES WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4U4- - 0 1117 13 8 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bo[binicm O 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> 0 6 LEREROFCREDIT O 6 EXEMPTION UYi 99 OTHER State Fund <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: 1.0 II.® III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTHOAY/YEAR <br /> Geor a Takemori Administrator 3-23-95 <br /> LOCAL AGENCY USE ONLY V Re,c L D <br /> COUNTY# JURISDICTION# � /F')ACILfT�Yi �1LAy <br /> LOCATION CODE -OPTIONAL BUPVISOrt-DISTRICT CODE -OPDONAL <br /> THIS FORM MUST BE ACCOMPANI RE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMAmmmy. <br /> FORM A(393) OWNER <br /> }�(J <br /> OWNER MUST FILr'FJLS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> _ V <br /> OIC d-YL&0 y',gyZ'KS OT„ <br />