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CA-0 <br /> `I ,NEW w<°w� a �o <br /> STATE OF CALIFORNIA '� <br /> STATE WATER RESOURCES CONTROL BOARD 3� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� we <br /> a Y/ p <br /> O„M,n <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ® 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED <br /> ONE ITEM Ej 2 INTERIM PERMIT 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) _ _ -- <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Penske Truck Leasing CO., L.P. ::.Irvironment_al Services <br /> ADORESS REST CROSS STRE PMCELa(OPrgNAy <br /> 1950 Bast Miner Avenue <br /> CITY NAME STATE 7� QODE-4554 +�IEPHOVEFj TNABEA CODE <br /> Stockton CA k OY 9 L—LO(/G <br /> ✓ Boz <br /> T,/ BOX I�CORPORATION 0 INDIVIDUAL PARTNERSHIP DOCARLIC GS NCV 0 COUNTY-AGENCY 0STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR gESEIF RVNDIAN A OF TANKS AT SITE E.P.A. I.D.N(oplioIwk <br /> 0 3 FARM 4 PROCESSOR [JLI 5 OTHER OR TRUST LANDS 3 <br /> EMERGENGY.CONTACI.PERSON.(RAIMARY}---- _ EMERGENCY CONTACT PERSON (SECONDAAYJ "D�1161i8f- '-"-- <br /> DAYS: NAME(LAST.FIRST) - PHONE N WITH AREA CODE AVS: NAME(LAST,FIRST) r',-942-1804 <br /> Jon Foster --77-1450 Bill Steward <br /> CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE IGHTS: NAME(LAST,FIRST) <br /> X <br /> SAME -AM <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED - - <br /> NAME ) CARE OF ADDRESS INFORMATION <br /> Penske.Truck Leasing Co., L.P. Lnviruvnental ServarFes <br /> MAILING OR STREET ADDRESS ✓ box Io indicate INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> Route 10, Green Bills, P.O. BOX 563 CORPORATION PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME - - STATE ZIP CODE PHONE S WITH AREA CODE <br /> Reading PA 19603-0563 610 775-6000 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> Penske Truck Leasing Co., L.P. 6nvironment_al Servcies <br /> MAILING OR STREET ADDRESS ✓box bindicab OINDIVIDUAL LOCAL-AGENCY DSTATE AGENCY <br /> Route iD, Green Hills, P.O. BOX 563 ®CORPORATION OPARTNERSHIP <br /> D COUMYAGENCY I FEDERAL STATE-AGENCY <br /> CITY NAME STATEZIP CODE P O FT M A E <br /> „--„ „2 PA 1960—0563 �G � - .. <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HO 7474 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkaN I SELFINSURED Q 2 GUMANTEE (� 3 INSURANCE O A SURETY BOND <br /> O 5 LETTER OF CREDT D 6 EXEMPTION O w 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.❑ II.Et Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED NATURE MMWr APPLICANTS TITLE DATE TWDAYNEAR <br /> V.P. Envir. Serv. <br /> LOCAL AGENCY USE ONLY Al 6� <br /> COUNTY# JURISDICTION# FACILITY e <br /> ® y- <br /> LOCATION ,5 -OPTIONAL CENSU ,4OPTIONAL BUPVIE_O�aT TCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY�T A T(1)OUR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ,A <br /> FORM A(S91) —/D ( O' FOR0037A5 <br />