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P�gQUR Cg cU <br /> STATE OFCAUFORNIA ° <br /> STATE WATER RESOURCES CONTROL BOARD F., „L$ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR(; A <br /> e4i��cnN'� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT S RENEWAL PERMIT X 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED - <br /> =MARK � 2 INTERIM PERMIT � 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAMEOF OPERATOR <br /> D <br /> BA ORCILITY NAME BRAD MONIZ <br /> D SUPPLY HARDWARE DISTRIBUTION CENTER NEAREST CROSS STREET PARCELNYOPTIONAL) <br /> GRANT LINE <br /> ORTH MAC ARTHUR DRIVE SITE PHONE WITH AREA CODE <br /> STATE ZIP CODE <br /> — CA 95376 209833-3100OX CORPORATION [] INDIVIDUAL PARTNERSHIP a LOCAL-AGENCY ] COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> CATE D 11 ISTRICTS <br /> 11,11111, IF INDIAN A OF TANKS AT SITE E.P.A. L D.#(optional) <br /> USINESS 1 GAS STATION 0 2 DISTRIBUTOR RESERVATION 1 <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> FNICWfWA <br /> YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 'DrAYYS: NAME(LAST,FIRST) <br /> BRAD MONIZ 209-833-3100 IN 4©8 –2AREA <br /> ME(LAT�FIA571 209- 29PHyI�E�#ZWITHAREACODE HTS' NAM LAST,FIRS <br /> MU1P+V1 f�L <br /> II.' PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NA©RCHARD SUPPLY HARDWARE T <br /> box to indicate 0 INDIVIDUAL [] LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESSP. b,C <br /> ]CORPORATION L PARTNERSHIP L] COUNTY-AGENCY FEDERAL-AGENCY <br /> CIS IMEJOSE, CA �~ STA& ZI D � PHOLF WI <br /> 1RE <br /> Tab <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) M_:] <br /> INFORMATION <br /> FNAMEF OWNER ANDINHARD SUPPLY HARDWARE0 INDkVIDUAL [] LOCAL-AGENCY b]STATE-AGENCY OR STREET ADDRESS0 VIA DEL ORO [] PARTNERSHIP 0 CyO�UQCNTVTY-AGj'EEVNCYyy �y,QF�EDERAL-AGENCYME �mr: pCWg 11fiffflC E <br /> SAN ,TOSS <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0 3 4 3 2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED a SURETY BOND <br /> 7',I SELF-INSURED 2 GUARANTEE [] 9 INSURANCE <br /> ✓ <br /> box toindicate fi EXEMPTION 099 OTHER <br /> 0 5 LETTEROFCREDR <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or Il is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] it.P III- <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&SL TUBE) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> HARRY FISHER CONSTRUCTION MANAGER 5/13/92 <br /> LOCAL AGENCY USE 0 LY –19 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT A -OPTIONAL <br /> SUPVISOR-OIST ICT 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 /> FORM A(5-91) _� <br /> 09 so <br />