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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A7'9 �� <br /> COMPLETE THIS FORM FOR EACH FACILMBITE -�® <br /> r - i, <br /> O is 7a Z In <br /> MARK ONLY � I NEW PERMIT 0 3 RENEWAL PERMIT `.N��- � e <br /> ONE ITEM 2 INTERIM PERMIT 0 5 CHANGE OF INFOSITE CLATIONOSURE O ] PERMANEN=CLOSEp„ <br /> Q 0 AMENDED PERMIT [] 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> 17 W. Elm St . parking lot NAMEOFOPERATOq <br /> ADDRESS The City of Lodi <br /> 17 W. Elm St . NEAREST CROSS STREET PARCEL#(OF noNAL) <br /> CITY NAME Sacramento St . <br /> Lod i STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Box T� CA <br /> TO INDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP Xj LOCAL-AGENCY 0 CDUNTY-AGENCY' <br /> DISTRICTS O STATE-AGENCY' O FEDEFUL-AGENCY' <br /> noOFBU BUSINESS <br /> Ac#genry,axry Ne eN roeowng rem#d sµNN #ra tlbbbn,#earn#r afire whrA OP110”IN UST <br /> TYPE OF BUSINESS O 1 GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE ERES VATIOM .P.AL 1.D.#(gofion#l) <br /> Q 3 FARM O 4 PROCESSOR ® 5 OTHER OR TRUST LANDS 1 J9 2 i Std <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY). �7 <br /> DAYS: NAME LAST,FIRS ( Y).Optional <br /> ( T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> F _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Same as above <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> The City of Lodi <br /> MAILING OR STREET ADDRESS ✓ hu b in r., <br /> 0 wDmouu Ej LOCAL-AGENCY [:3 STATE-AGENCY <br /> 221 W. Pine St 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY = FEDERAL- <br /> AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Lodi, CA 95240 (209)333-6706 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER The City of Lodi CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ butoMiwN 0INDMDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 221 W. Pine St. O CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> Lodi, CA 95240 209 33 - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bmroi�Me O I SBF-INSURED 0 2 GUARANTEE 3]8 INSURANCE O 4 SURETY BOND O 5 LEFTEn OFCREDTT O s EXEMPTION O]STATEFUND <br /> 08 STATE FUND BCHIEF FINANCIAL OFFICER LETTER O9STATE FUND BCERTIFICATE OFDEPOSIT OIOLOCAL GOVT.MECHANISM O99OTHER <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.ED II.S III.a <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 OWNER'S TITLE DATE MONTWDAYNEAR <br /> )� w.3 ),�� Sr Civil Engineer 3/23/01 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# a`// <br /> m t-t 0o az �tl-T�T7� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL /� 7-lq <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 T" 'FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UI (GROUND STORAGE TANK REGULATIONS <br /> FORM A(695) �# 11 ( I <br />