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bbOVe C <br /> f ti <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD (;$ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A �i <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE ° <br /> t NEW PERMR 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION Q 7 PERM G SI <br /> MARK ONLY <br /> 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE P ELIC H- <br /> ONE REM Q z INTERIM PERMIT � <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)of OPERATOR <br /> nRA OR FACILITY NPM) <br /> Charlies Day & Ni t Lock & Ke Service NEARESTCROSSSTREET PARCELf(OPTDNAU <br /> ADDRESS <br /> 06 E do St STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CITY NAME CA 5203 (2"""- <br /> Stockton, <br /> ✓ SOX INDIVIDUAL PARTNERSHIP LOCALAGENCY COUNTY-AGENCY' STATE-AGECY• O FEDERALAGENCY' <br /> =1 CORPORATION <br /> DISTRICTS' <br /> TO INDICATE <br /> •N owr of Uppb agency,ST Ie a pagen ,wMW9 the IoNoYAng:name of Supervisor of division,section,or office which✓a <br /> neINDIAN a OF TANKS AT SITE E.P.A. I.D.a(apfimap <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlorMl <br /> DAYS:NAME MST.FIRST) PHONE,WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE a W LTH AREA CODE <br /> Skobrak Charles 20 4 — PHONES WTH MEA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE,WITH AREA CODE NIGHTS:NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> rArlesSkobrak i bwb MkaMNDIv1ouAL O LOCAUAGENCV STATE AGENCY <br /> NG OR STREET ADDRESS DOfIPOMTION PARTNERSHIP COUMY-AGENCY FEDEMLAGENCY <br /> 706 N El Dorado St. — STATE ZIP CODE PHONE,WITH AREA CODE <br /> CITY NAME E CA <br /> ( Stockton, <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NpME0 OWNE <br /> L.ClarMeS kobrak <br /> ✓boa bYdkaM DIYIDUAL OLOCAL-AGENCY STATEAGENCY <br /> MAILING OR STREET ADDRESS <br /> 706 N. El Dorado St. 0 CORPORATION PARTNERSHIP �COUNfYAGENCY FEDERALA <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> CITY NAME <br /> Stockton <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> 1 SELF-INSUflEO O 2 GUAMNnE I�7 INSURANCE D,SURETY 80X0 <br /> ✓ to,,b iMicaN a EXEMPTION =so OTHER <br /> 8 TTEROFCREOn <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.[]R] 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> �harles E <br /> OWNER'S TITLE DATE MONTWDAY/YFAR <br /> kobrakSIGNED) <br /> Owner <br /> LOCAL AGENCY USE ONL <br /> C(DUN7Y a <br /> JURISDICTION, FACILrrY* QgCjB <br /> __ 9UPVISOR-DISTRICT CODE -OPTpNAI. <br /> _ l Q t <br /> LOCATION CODE - IONAL CENSUS TRACT,-OPTIONAL - <br /> PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE IIF RMATKIN ONLY, 'W <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMP:ENENTING THE UNDERGROUND STORAGE TANK REGULATIONS FQvAMM 0 <br /> FORM A(3X3) <br />