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\1 STATE OF CALIFORNIA :F``'�••.•.- ��3 •' <br /> STATE WATER RESOURCES CONTROL BOARD ALI W e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> IBJ COMPLETETHIS FORM EACH CILRYISUE <br /> 3 NEW PERMIT 3 RENEWAL PEMI <br /> RT Q 5 ANGE OF INFORMATION E 7 PERMANENTLY CLOSED S <br /> MARK ONLY <br /> ONE REM z INTERIM PERMIT O A AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> � <br /> L FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAMEOFOPERATOR <br /> DEA OR FACILITY NAME Sithe Energies USA Inc,/Rich Recor <br /> Cogeneration National COrP- PARCEL'(OPTIO"L) <br /> NEAREST CROSS STREET <br /> ADDRESS <br /> 2526 W. Washington Street W. Washin ton St, <br /> STATE ZIP CODE SITE PHONE P WITH AREA CODE <br /> CITY NAME <br /> CA 95203 209 467-3838 <br /> Stockton <br /> ro/ Box <br /> xTE IM CORPORATION Q INOMOUAL Q PARTNERSHIP Q DISTRICTS <br /> Q CoUN Y-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> J IF INDIAN A OF TANKS AT SITE I E.P.A. L D.0((0P1W ry <br /> TYPE OF BUSINESS Q 1GAS STATION Q 2DISTRIBUTOR = RESERVATION <br /> Q 3 FARM Q A PROCESSOR ® 5OTHER OR TRUSTLANOS 2 CALQ¢¢�29222 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.PAST) PHONE 0 WITH AREA CODE OAYS:NAME(LAST,FIRST) (209)467-3838 <br /> Recor Richard (209)467-3838 Ta for Kyle <br /> NIGHTS: NAME(LAST,FIRST) PHONEA WITH AR'cA CODE NIGHTS: NAME;LAST,FIRST) (209)474-3794 <br /> Recor, Richard (209)334-1602 Taylor, Kyle PH c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Port of Stockton <br /> MAILING OR STREETADDRESS V =b� Q INDIVIDUALQ LOCAL-AGENCY QSTATE-AGENCY <br /> 2201 W. Washington St. QCORPORATION Q PMTNE'nSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE i ZIP CODE PHONE A WITH AREA CODE <br /> Stockton CA 95201 (209)946-0246 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Cogeneration National Cor <br /> MAILING OR STREET ADDRESS ✓ � w Q INDIVOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 2526 W. Washington St I CORbPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY HANE I STATE MP CODE PHONE a WITH AREA CODE <br /> Stockton CA i 95203 (209)467-3838 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4—F47]-1 013 1 312= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Uw biMinN 0 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q t SURET!BOND <br /> 0 5 LETTEROFCREDT 0 9 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E] IL Q III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPL:CA!{TS NAME D ATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR <br /> Richard A, Recor General Manager 8/20/91 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION n AGILITY a <br /> LOCATIONE,E -OPTIONAL CENSUS RACT0 - iIONAL iSUPVIy�QR-DISTRICT CODE b ql <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 A15.911 FOR013JA-5 <br /> 1r `— ��� <br />