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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z` `°�• ' <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'A�•oan" <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED 517 <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a o <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W <br /> 01 <br /> FACILITY/SITE NAME C CARE OF ADDRESS INFORMATION <br /> Stockton Plating Inc . CD <br /> ADDRESS NEAREST CROSS STREET ✓BP lod D PMTN'MW D STATE-AGENCY <br /> t Z s^ (� H U n t e r Y) �GMTON D LGcu-MVV D RDBM4AGENLY <br /> ❑ MWDUAL D WXY AGEN9 <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Stockton CA 95206 209-948-1101 <br /> PEOFBUSINESS: ❑2 DISTRIBIfT A PROCESBDR ✓Bo%NINDIAN EPA ID N <br /> ❑ I GAS STATION 3 FARM X 5 OTHFA RESERVATION a R,0 TANK'# <br /> ❑ TRUSTLANDS ❑ CAD009212929 AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Huntley , Robert E . 209-948-1101 <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA OCDE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> Huntle Robert E . 209-931 -2234 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stockton Plating Inc . <br /> MAILING w STREET ADDRESS Sox to indicate D PARTNERSHIP D STATE-AGENCY <br /> 632 S o . E 1 Dorado S t CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Stockton CA 95206 209-948-1101 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stockton Plating Inc . <br /> MAILING w STREET ADDRESS Box to indicale D PARTNERSHIP D STATE-AGENCY <br /> 632 S D . El Dorado S tCORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY•AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> Stockton CA 95206 1209-948-1101 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ® IN.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENA OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS.TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> Robert E . Huntley X At v i,1p <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION k AGENCY# FACILITY ID# of TANKS at SITE <br /> 7H 1oo11 1Ct �s6 000 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE t WITH AREA CODE <br /> 5-roc-l< 63 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ED <br /> o I Z3 X07 32-3 YES ❑ NO ❑ 3 GJ/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BT: <br /> �• y C- <br /> THIS FORM MUST BE ACCOMPANIED RY A LEAS n10R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 2 <br /> I 1 {ORM A(3-2-88) /lL <br /> DATA PROCESSING COPY U <br />