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AtgO�p BS r <br /> STATE OF CALIFORNIA ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A A <br /> ms <br /> • C�l1I lJNN,' <br /> COMPLETE THIS FORM FDR EACH FACILITYlSITE <br /> �J t�NEWPERMIT ] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION _I� 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY _ �03 ONE ITEM r� 2PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE'INFORMATION& ADDRESS- (MUST BECOMPLETED) <br /> EOFOPERATOR <br /> DBA ORp�FACIL17Y NAME TN f1T{}R TRUCVC <br /> CONNELL MO!QR- TRK"D-'--��`" — - NEAREST CROSS STREET <br /> ADDRESS 1 I'r <br /> 2,2�1 IV- �f ILSQ�I--W STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME CA 95205 209 948-3434 <br /> PATE ' l CORPORATION INDIVIQUAL I] PARTNERSHIP LOCAL-AGENCY [] COUNTY-AGENCY � STATE-AGENCY n FEDERAL-AGENCY <br /> ✓ IF INDIAN #OF TANKS AT SITE F.P.A. 1.D.#(optional) <br /> TYPE OF BUSINFSS 1 GAS STATION 2 06STRIBUTOR 0 RESERVATION <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS 3 CAT000613963 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WIT(H�AREAC�ODE DAYS: NAME(LAST,FIRST) 2091 9(}$_3434 <br /> 94P, X434 4�1a 1d 1 LTLLARFA�L]E—�— <br /> HECKM.AN,L-8E.FIZOI�-- - <br /> NIGHTS: NAME{LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: AME(LAST,FIRST} — <br /> HECKMAN SHELDON 209 952-1675 WADY PHI <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME ren <br /> CORR�t M0TG TR I{ �, — boxtobdicate INDIVIDUAL �i LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS CORPORATION [� PARTNERSHIP [] COUNTY-AGENCY t� FEDERAL-AGENCY <br /> I7___�___BOX 8�i^�-- ATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME CA. 95208 209 948-3434 <br /> STOCKTON i� <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) CARE OF ADDRFSS INFORMATION <br /> NAME O`FIO1WNER��r�❑ <br /> CGNNEL1� 1�1 V�1—T / boxwind4ale INDIVIDUAL LOCAL-AGENCY L]STATE-AGENCY <br /> MAILING OR STREET ADDRESS CORPORATION PARTNERSHIP [:71 COUNTY-AGENCY I-_-] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME CA. 95208 209 9483434 <br /> STOCKTON <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(915)323-9555 it questions arise. <br /> TY (TK) HO i 4 ��'C <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED a SURETY BOND <br /> CI 2 GUARANTEE 4 3 INSURANCE Ej <br /> C7 1 SELF-INSURED 99 OTHER <br /> ox toindicaie E-1 5 LETTEROFGREDIT i�6 EXEMPTION <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will he sent to the tank owner unless box I or A is checked. <br /> GF{ECK ONE BOX INDICAT WG WHICH AROVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I,` ) I1.4 II1.1_7 <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&SIGNATU ) <br /> APPLICANT'S TITLE DATE MONTHIDAYlYEAR <br /> SHELDON HECKMAN PRESIDENT 3 17 93 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> r � ��(� <br /> `I - <br /> LOCATION COD OPTIONAL <br /> CENSUS TRACT z OPTIONAL sj SUPVISOR TRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(1'2 911 00 <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION 'CR6933A R6 <br /> ?Ck �' 1 K <br />