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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> d� m' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '� <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Vivian Gatzert Property <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 500 E. Oak St. Garfield <br /> CITY NAME STATE ZIP CODEC>Z SITE PHONE#WITH AREA CODE <br /> Stockton �t CA 2t� N/A <br /> ✓Box ED CORPORATION IJ INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I ownerof UST is a public agent.mmpkle the folbwng.nems of sipernsord division,sedbn or Or"whirl)operates the UST <br /> TYPEOFBUSINESS O 1GASSTATION Q 2DISTRIBUTOR Q ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.0(optionao <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR ® 5 OTHER OR TRUST LANDS I CAC 001350872 <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 /> Vivian Gatzert (209)369 6852 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Vivian Gatzert <br /> MAILING OR STREET ADDRESS ✓ boxtookale ] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 108 N. Lee St. 000RPORATION Q PARTNERSHIP O COUNTY-AGENCY [___l FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Lodi, <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Vivian Gatzert <br /> MAILING OR STREET ADDRESS ✓ boxlondimte [INDIVIDUAL EDLOCAL-AGENCY EDSTATE-AGENCY <br /> 108 N. Lee St. E:3 CORPORATION =PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-14--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to induale = 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND O 5 LETTEROFCREDIT O 8 EXEMPTIONI�7 STATE FUND <br /> ®8 STATE RIND&CHIEF FINANCIAL OFRCER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 99 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: 1. <br /> THIS FORM HAS BEEN COMPLETED LIND PE ALTYO URY, ZTO THE BEST OF MY KNOWLEDGE,ISTRUE AND CORRECT <br /> TANK OW RD'S NAME(PRI ED& GNATURE) &0 ANK OWNER'S TITLE DATE MONTMAYNEAR <br /> /d/a,t' U- 2n= 1 OWNER 3/9/98 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#0646/ <br /> m 0 7 1 g C <br /> LOCATONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br />' ,U2 a11y� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN ORMATION ONLY. <br /> FORMA(6.95) OWNER MUST FILE THIS FORjW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(e STORAGE TANK REGULATIONS <br />