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- • � 460uF < <br /> P P t^ <br /> P <br /> STATE OF CALIFORNIA ^` ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY g TEMPORARY SITE CLOSURE <br /> ONE ITEM F-12 INTERIM PERMIT O 4 AMENDED PERMIT <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED)OF OPERATOR <br /> DBA C R_FAC ILITY N AM E BerCRO <br /> k Thom son <br /> Ro—Tile Inc PARCELN(OF(OPTIONAL) <br /> NEAREST SS STREET <br /> ADDRESS <br /> 1615 South Stockton Street STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME CA <br /> Lodi <br /> T / Box <br /> o INDICATEM CORPORATION [-IINDIVIDUALO PARTNERSHIP 0 LOCAL-AGENCY IEDCOUNTY-AGENCYO STATE-AGENCY FEDERAL-AGENCY <br /> ✓ IF INDIAN CTS #OF TANKS AT SITE E.P.A. I.D.#(apfionalJ <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR RESERVATION <br /> O 3 FARM O 4 PROCESSOR ® 5 OTHER OR TRUST LANDS 2 <br /> RGENCY CONTACT PERSON (SECONDARY)•optional <br /> EMERGENCY CONTACT PERSON (PRIMARY) EME <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Thompson, Berk 209-334-1380 <br /> NIGHTS: NAME(LAST,FIRSTI PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Thompson, Berk 209-334-1380 PwnNI <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> Ro-Tile Inc. ✓ bUlDindkate <br /> MAILING OR STREETADc. INDIVIDUAL Q LOCAL STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> P.0. Box 410 STATE ZIP CODE PHONE#WITH AREACODE <br /> CITY NAME OA 95241 209-334-1380 <br /> Lodi <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> LNAMEOFOWNER <br /> ile Inc boxbIndlcate STREET ADDRESS INDIVIDUAL LOCAI-AGENCY OSTATE-AGENCY <br /> BDx 410 _ 5PCORPORATION PARTNERSHIP COUNTY-AGENCY l� FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA 95241 209-334-1380 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> L J 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED 0 2 GUARAMEE (] 3 INSURANCE Ij 4 SURETY BONG <br /> ✓ box b Indicat< N OTHER <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E-] it.R-] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED NATU ) <br /> APPLICANTS TITLE DATE MONTHMAYNEAR <br /> Berk Thompson Vice President <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> fill <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL S - C CODE -OPTj0NAL f.1, � L/ q(Z/ <br /> o Z Z3 . 75z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 LYYj <br /> FORM A(5-91) A�'pJ <br />