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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A o <br /> �I COMPLETE THIS FORM FOR EACH FACILITYISITE Is <br /> MARK ONLY PJ I NEW PERMIT r7 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION O 7 PERMANE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 9 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Gateway Project City of Stoc ton Ivva:-1iC: <br /> ADDRESS Block bounded by Lafayette, NEAREST CR SS STIR PARCEL#(OPTIONAL) <br /> E1 Do S. i N q -01101 -07 <br /> CITY NA ETTATE ZIPrI5E SITE PHONE#WITH AREA CODE <br /> Stockton CA <br /> ✓BOX I1 CORPORATION 0 INONIDUAL D PARTNERSHIP ]LOCAL-AGENCY O COUNTY-AGENCY' ED STATE-AGENCY' O FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> '#ovmero(USTBa pubic ageq.mmpNb the(oinwilg:name d eWeNisorof Eivisbn,section oroft Ach o0netes the UST Mr- Hon PaInquist <br /> TYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTOR RESV IF INDIAN I ERVATION #OF TANKS AT SITE I E P.A. I.D.#(optional) <br /> Unknown Q 3 FARM Q # PROCESSOR 0 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Crawford, Jobn (EBI) 925-443-0225 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Crayford, Jobn EBI 925-396-8200 <br /> I1. PROPERTY OWNER INFORMATION-(MUST BE COMIPLFTF_D) <br /> NAME CAAfI�EOFADDRESS"IF M_AT.I�ON��� '\ <br /> Mr. Hon Pa uist {10u5I (I b 1�1G i 11�6N� !J^ + <br /> MAILING OR STREET ADDRESS ✓ haloes=' E:] INDIVIDUAL fR LOCAL-AGENCY O STATE-AGENCY <br /> 305 N. El Dorado Street - SLL l Tb 2zl) O CORPORATION O PARTNERSHIP = COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 95202 209-937-8538 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ORE OF ADD RESSINFO)RMATION r ���Jp� <br /> Mr. Ron Palmquist LLSk 46 4 ��L L1` /)1 Y•"'-"... <br /> MAILING OR STREET ADDRESS ✓ bWomdmla =INDNIWAL AM LOCAL-AGENCY OSTATE-AGENCY <br /> 305 N. El Dorado Street — Su-a-, 2-V 0 CORPORATION =PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> Stockton CA 95202 209-937-8538 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Pay to hifta1 SELFdNSURED =1 2 GUARANTEE 0 3 INSURANCE I1 A SURETY SONO =5 LETTEROFCREDR =6 EXEMPTION O 7 STATE FUND <br /> B STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 110 LOCAL GOVT.MECHANISM 199 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.Q II.® III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTEDB SIG TANK <br /> i51pl� OWNER' 4 DATE <br /> MONTHDAYNEAR <br /> L <br /> LOCAL AGENCY USE ONLY 1 <br /> COUNTY# JURISDICTION# F !;- q <br /> ms s t T)D �S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL p x l� <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 �'i THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI WORAGE TANK REGULATIONS <br /> FORM A(6-95) `� \� <br />