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At <br /> STATE OF CAUFOPMA ° <br /> STATE WATER RESOURCES CONTROL BOARD r� � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A rFDKO' <br /> ' COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q NEW PERMIT <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT <br /> 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> I: F CILITYlSITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> OR FACILITY NAME Riv <br /> NEAREST CROSS S BEET <br /> PARCEL M(OPTIONAL) <br /> ADDRESS Brad f ord <br /> 2211 N. Wilson w d ( STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CITY NAME CA — <br /> -AGENCY <br /> `l BOX CORPORATICN 0 4NDIVIDUAL !] PARTNERSHIP [� LOCAL-AGENCY ED COUNTY-AGENCY' E�] STATE-AGENCYLD FEDERAL ' <br /> TO INDICATEDISTRICTS' <br /> II owner°f UST is a public agency,complete She t°I4owing:name of Supervisor of division,sect on,or office whic�opel NDIAN IF I A OF TANKS AT SITE LIST <br /> E.P.A. I.D.N fop <br /> 11 <br /> TYPE OF BUSINESS i GAS STATION 0 2 DISTRIBUTOR � RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (SECONDARY)-option®I <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ENII.HTS: <br /> NAME(LAST,FIRST) PHONE x WITH AREA CODE201 q4 <br /> o — PHONE x WITH AREA CODE <br /> PHONE a WITH AREA CODE N4GWT5: NAME(LAST.FIRST) 209 952-1675 <br /> NAME(LAST.FIRST) Heckman Sheldon <br /> r Answering Machine 916 371-4960 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> Connell Motor Truck Co. Inc. ✓ box 13indicas � INDIVIDUAL L] LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS CORPORATION � PARTNERSHIP COUNTY-AGENCY FEDERAL <br /> P, 0, BOX STATE ZIP CODE PHONE s WITH AREA CODE <br /> CITY NAME Ca. 95208 209 948-3434 <br /> Stockton <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> Connell Motor Truck Co. , Inc, / box mindcate INDIVIDUAL LOCAL-AGENCY Ci STATE-AGENCY <br /> MAILING OR STREET <br /> ADDRESS [7=71 CORPORATION PARTNERSHVP Q COUNTY-AGENCY � FLUERAL-AGENCY <br /> P- 0, BOX 8467 STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME Ca. 95208 209 948-3434 <br /> Stockton <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ4 4- - If? A� b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USEDa suRl rY BOND, <br /> SELF-INSURED [D 2 GUARANTEE [_j 3 INSURANCE <br /> ,/ boxbindkale []6 EXEMPTION 99 OTHER <br /> 1 5 LETTEROFCREiT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or N is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> L❑ it. IIL <br /> CORRECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,D TRUE ANO wDAY1YF_AAR <br /> OwNER'S TITLE <br /> WNFR-S ME(PRINTED&SIGN <br /> ED <br /> onneyj Motor TrucC <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION# FACILITY <br /> COUNTY# Eff[` n <br /> SUPVISDR-D/ISTRICT CDDE •OPTIONAL L <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL G cP�/ <br /> UNLESS THIS 15 A CHANGE OF SITE ON <br /> THIS FORM.MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMfI'APPLICATION FORM!MlNDERGROUND STORAGE TANK REGt1LATKIN8�� ONLY <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING tcEtr � <br /> FORM A("33) <br /> �� �� 4, <br />