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a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILRY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION © 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 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 /> American Savings Bank <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPfIONAL) <br /> 1888 Lockheed Court C . E . Dixon <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA-CODE <br /> Stockton CA <br /> ✓ BOX {x� <br /> TO INDICATE IJ CORPORATION [ INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY I] COUNTY AGENCY ED STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION = 2 DISTRIBUTOR -/ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional/ <br /> 0 3 FARM 0 4 PROCESSOR t 5 OTHER OORTRUSTLANIDS y CAC000790168 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Alonzo Jess 209-546-6703 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) E -- <br /> Alonzo , Jess 209-546-6703 PUQNE a WITH AREA <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> American Savin s Bank F . A . <br /> MAILING OR STREET ADDRESS ✓ box 0Indicate = INDIVIDUAL 0 LOCAL-AGENCY <br /> 41710 F Main St - 4th Elnnrf]CORPORATION D STATE AGENCY <br /> CITY NAME f] PARTNERSHIP ] COUNTY-AGENCY ] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE x WITH AREA CODE <br /> Stockton CA 95201 209-546-6703 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> American Savings Bank F . A . <br /> MAILING OR STREET ADDRESS ✓ Lox bindkale INDIVIDUAL <br /> 400 E . Main S t . - 4th Floor D LOCAL-AGENCY STATE AGENCY <br /> CITY NAME O CORPORATION I] PARTNERSHIP I] COUNTY-AGENCY O FEDERAL AGENCY <br /> STATE <br /> Stockton A ZIP95201 CODE PHONE WITH AREA CODE <br /> C <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -u <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box 1,d4at. 1 SELF-INSURED I:12 GUARANTEE L_J 3 INSURANCE <br /> D 5 LETTER OF CREDIT Q6 EXEMPTION D d SURETY BOND <br /> ] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1.❑ II.[_�] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIG TURE) APPLICANT'S TITLE <br /> DATE MONTH/DAV/VEAR <br /> tolLaa�- s 4 zr q3 <br /> LOCAL AGENCY USE ONLY <br /> C # JURISDICTION# FACILITY# <br /> IL �q � � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPDONAL SUPVISOR-DISTRICT CODE OPT/ONAL <br /> Z 323 <br /> FORSTHIISFORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ) <br /> ft� FOR0033A 5 <br />