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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONT L A ( 3 V••• o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ' 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) a� <br /> NAME OF OPERATOR � 1.� <br /> DBA OR FACILITY NAME / L4 <br /> 6P OIL., FACIL T 024-1 IS�W <br /> ADDRESS NEAREST CROSS STREET PARCEL 4(OPTK)NAW <br /> l AVE RIV zo <br /> CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE <br /> STOOKTON _ _ CA 9520'1 0 - 95 -4SlS <br /> T NDIICATE `CORPORATION C-j INDIVIDUAL [� PARTNERSHIP 0 LOCAL-AGENCV Q COUNTY D STATE AGENCY FEDERAbAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ❑ RIF ESEfl INDIAN A OF TANKS AT SITE E.P.A. I.D.#(oplimap <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS q- CAI, 930193446 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> AYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) q16— 631_ 6915 <br /> LOu <br /> 1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 8800-274.3512 <br /> BP 24 11 r-MER6044X De5K PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 'THRIF M olt_ Co ��� ��� P DA AMlCO <br /> MAILING OR STREET ADDRESS - J^\�'� ✓ Nax b indicate Q INDIVIDUAL LOCAL-AGENCY E__I STATE-AGENCY <br /> _ I0a ODd .AKI✓WQD MRCORPORATION =1 PARTNERSHIP 0 COUNTY-AGENCY [-I FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> DOWNEY CA 902 0-923-981 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFO ER \Ia' Kp`VaII// •CARE ADDRESS MATION <br /> LOUMARISA <br /> _ <br /> ILI�R STP ADDRESS ✓ box mindicala � INDIVIDUAL � LOCAL-AGENCY (] STATE <br /> S O.SS P�� �� (♦CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITU NAME F LL STATE ZIP CODE PHONE#WITH AREA CODE <br /> "O CoRCCN/A GA 5610 ro-GTSI-G9 IS <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER <br /> NUUMBER-/CCall(916)323-9555 if <br /> queesstions�s&j {v 0, <br /> TY(TK) HO 1.414 - 0 12E 70 �&] # W� py ''ri'nt, in <br /> V. PETROLEUM UST FINA ILITY (MUST BE COMPLETED)-IDEN Y TIJE METHOD(S) USED5 <br /> ✓ box ro'mdicate <br /> 1 SELF INSURED I�2 GUARAMEE 0 4 SURETY BOND <br /> ` 5 LETTEROFCREDIT 6 EXEMPTION L] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS egal notification andIlli 9 will ent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USEDONS AND BILLING: I.❑ II.❑ IIL- <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&SONATUREI APPLICANTS TITLE DATE MONTHMAYIYEAR <br /> ONES >z JAN 14 94 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FACILITY# <br /> E= <br /> LOCATIONCODE OPTIONAL CENSUS TRACT 4 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A R6 <br />