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�co�• y <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISTTE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SIY• <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACIL TE INFQ T BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> an Joaquin Regional Transit Dist . Same <br /> ADDRE NEAREST CROSS STREET PARCEL O(OPTIONAL) <br /> Wi son Way <br /> CITY NAME STATEZIP CODE SITE PHONE a WITH AREA CODE <br /> Stockton CA 95205 209-948-5566 <br /> TO INDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP XX LOCAL-AGENCY O COUNTYAGENCY' O STATE.AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a Pub9c agency,cor pish,the to9owing:name of Supervaor of division,esdlon,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS ATSITE E.P.A. I.D.•(opffonalY <br /> 0 3 FARM 4 PROCESSOR5 OTHER RESERVATION <br /> OR TRUST LANDS 6 <br /> [ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> Johnson, Tom 209-948-5566 Gualeni Dave 209-948-5566 <br /> NIGHTS: ME NA (LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Johnson Tom 209-745-6672 Gualeni , Dave 209-823-8618 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> San Joacruin Regional Transit Dist. <br /> MAILING OR STREET ADDRESS ✓boxblydkau INDIVIDUAL wLOCAL-AGENCY QSTATE-AGENCY <br /> 1533 E. Lindsay Street =CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDEML AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Stockton CA 95205 209-948-5566 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> aboveRAmp as <br /> MAILING OR STREET ADDRESS ✓ 6oab WiCW INDIVIDUAL O LOCAL AGENCY ED sTATE-AGENCY <br /> O CORPORATION [7:1 PARTNERSHIP O COUNTY-AGENCY O FEDEML-AGENCY <br /> STAT <br /> CITU NAME E ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 0 2 4 5 6 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓6mbiMicaN XX1 SELF-INSURED =12 GUARANTEE 0 D INSURANCE E:D 4 SURETYBOND <br /> 5 LETTEROFCREDIT =6 ExEMPTION D 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.Q III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGD) OWNEWSTITLE DATE MONTHOAYNEAR <br /> Dave Gualeni Maint . Coordinator 04/16/97 <br /> LOCAL AGENCY USE ONLY 23 <br /> COUNTY a JURISDICTION a FACILITY* <br /> m 101013MV41 <br /> LOCATIONCODE -OPTpNAL CENSUSTRACTO -OPTIONAL SUPVISOR-DISTRICT OPTIONAL <br /> 6 : L> <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 /> FORMA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> (3931 <br />