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• t <br /> STATE OF CALIFORNIA ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W�g a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE t"'t°""�� <br /> MARK ONLY LJ I NEW PERMIT F--j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> San Joaquin Re ional Transit DiSt. Same <br /> NEAREST CRSTREET PMCEU(OP DNAU <br /> ADDRESS <br /> c <br /> CITU NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CA 95205 209-948-5566 <br /> Stork <br /> TO Box 0 CORPORATION (]INDIVIDUAL PAIITNFASHIP IX DISTRICTS' <br /> LOCAL-AGENCY <br /> AL-AGNCY �COUNIY-AGENCY' ED STATE-AGENCY' O FEDERAL-AGENC)' <br /> N owner d UST Is a public agency,con-ii the following:harts,of Supervisor d division,section,or onim which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN NOF TANKS ATSITE E.P.A. I.D.#(optlanAg <br /> RESERVATION 6 <br /> Q 3 FARM 4 PROCESSOR ® 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> n Tom 66 Dave 209-948-5 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME ILAST,FIRST) PHONE#WITH AREA CODE <br /> 5-6672 GualeNr Dave 209-823-ti <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> a it Dist. <br /> MAILING OR STREE ADDES <br /> RS ✓ box biMbaY O INDIVIDUAL EX LOCAL-AGENCY OSTATE-AGENCY <br /> f O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209-948-5566 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot bNlOrals INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 p 2 4 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ hot binEbals "I SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE L- 4SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION O N 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: L II.O III. <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(PRINTEDB SIG ) OWNER'S TITLE DATE MONTHA)AVNEAR <br /> Dave Gualeni - �`° - Maint . Coordinator 1 04/16/97 <br /> LOCAL AGENCY USE ONLY :2 3 f-5 <br /> COUNTY# JURISDICTION s FACILE FY <br /> m <br /> LOCATION CODE - <br /> OPTIONAL CENSUS TRACT#-OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> IM <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrrE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FO MMR7 <br />