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s s ^�� - STATE OF CALIFORNIA +p STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A '' COMPLETE THIS FORM FOR EACH FACILrTYISITE "�• MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILrrY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME AME OF OPERATOR Janet E. Woods/Kathleen A. Merkl ADDRESS NEAREST CRO SS STREET PMCEL#(OPTgNAU 1912 Waudman Ave Thornton Rd. CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE Stockton CA I520 (20 )4 -1232 TOIN BOX 0 CORPORATION Q INDIVIDUAL I�PARTNERSHIP 0 LOCAL'AGENCY COUNTY-AGENCY' D STATEAGENCY' O FEDERAL-AGENCY' DISTRICTS' •If canner ol UST Is a public agency,corrplete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION/IFINDDaOF TANKS AT SITE E.P.A. I.D.a TepiI Q 3 FARM d PROCESSOR M 5 OTHER OR TRUST LANOS 1 CAC 001241560 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Same as above It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION Janet F. Wc)c)d-/Kathleen L—mprLpl MAILING OR STREET ADDRESS ✓EocbinNcsN INDIVIDUAL O LOCAL-AGENCY STATE AGENCY 1912 Waudman Ave. p CORPORATION O�OCF]PMTNERSHP COUNTY-AGENCY FEDERAL-AGENCY CITY NAATtoCkton, CA 95209 STA ZIP c§'E209 PF�ONE,(1(JITIJ,AFIEI��QDE, III, TANKOWNER INFORMATION-(MUST BE COMPLETED) y7 `LU)f 4( / L�L NAME OF OWNER CARE OF ADDRESS INFORMATION Janet E. Woods/Kathleen A. Merkel MAILING OR STREET A0211 ✓ omosocam Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY 1912 EWau�man Ave. 0 CORPORATION M PARTNERSHIP 0 COUNTY AGENCY = FEDERAL-AGENCY CITY NAMESTg1E ZIP CODE PHONE a WITH AREA CODE A 95209 (209)477-1232 Stockton, C IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED -/bUbirmi Q� 1 SELF-INSURED O 2 GUARANTEE L-13 INSURANCE O A SURETY BOND 17)5 LETTER OF CREDIT I=&ExEwrnoN O BD OTHER CSUSTCF VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked, CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.® II.0 IN THIS FORM HAS BEEN COMPLETED UNDER PENAL T OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&S IGNE OWNER'S TITLE DATE MONTWDAYNEAR Patrick J Merkel Owner 2/18/97 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION a FACILITY ® t5 2 2'Zl LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUF7 w -DISTRICTCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS WR)D33AA7 FORM A(303) 0