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'ObOJw [ f <br />STATE OF CALIFORNIA •T o "� <br />/ STATE WATER RESOURCES CONTROL BOARD w ,,,� v <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �;a „ � <br />f4 VOe N•� <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ® 7 PERMANED S� <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br />Kv'nI ennA#ATIAKI o. AnnRCCC- lWII ICT RF MMPI FTFnl <br />I. f"/iMlLll I I J . u.. v. u.. r.. <br />DBA OR FACILITY NAME <br />DiSelvo Trucking <br />1— - __ _- __ <br />Co. <br />_ <br />NAME OF OPERATOR <br />Joe Keenan <br />NIGHTS: NAME (LAST, FIRS T) PHONE #WITH AREA CODE <br />ADDRESS <br />Tun er John 510 531-SC11PHONE <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />1444 Lathrop Rd. <br />1] CORPORATION 0 PARTNERSHIP <br />S. McKinley <br />CITY NAME <br />CITY NAME <br />ZIP CODE <br />STATEZIP CODE <br />SITE PHONE #WITH AREA CODE <br />San Francisco <br />CA <br />953301(209)858-2531 <br />LathropCA <br />v BOX <br />CORPORATION <br />INDIVIDUAL PARTNERSHIP <br />LO -AGENCY COUNTY -AGENCY <br />STATE -AGENCY FEDERAL -AGENCY <br />TO INDICATE <br />DISTRICTS <br />I <br />TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR <br />INDIAN <br />RESERVATION <br /># OF TANKS AT <br />SITE <br />E. P. A. I. D. # (apto-W) <br />3 FARM <br />E-] 4 PROCESSOR [t/j <br />5 OTHER <br />OR TRUST LANDS <br />7 <br />CAD 98160516 <br />FMPRrFNCY CnNTArT PFRSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />Keenan Joe (209)858-2531 <br />PHnNF I WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRS T) PHONE #WITH AREA CODE <br />NIGHTS: NAME(LAST, FIRST) <br />Tun er John 510 531-SC11PHONE <br /># WITH AREA CODE <br />n n0nnC0TV n1AIKICR IIUmRMATInNI - (RAI1CT RF CnNIPI FTFDI <br />NAME <br />CARE OF ADDRESS INFORMATION <br />DATE MONTWDAYNEAR <br />DiSalvo Trucking Co. <br />John Tunger <br />MAILING OR STREET ADDRESS <br />✓ boxbiWi¢ 0 INDIVIDUAL <br />ED LOCAL -AGENCY 0 STATE -AGENCY <br />PO B o x 1-93765 <br />1] CORPORATION 0 PARTNERSHIP <br />O COUNTYAGENCY O FEDERAL AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />San Francisco <br />CA <br />s <br />1 (415)864-3337 <br />III TANK nWNFR INFORMATION - (MUST RF COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />DATE MONTWDAYNEAR <br />DiSalvo Trucking Co. <br />John Tunger <br />MAILING OR STREET ADDRESS <br />✓ bar bindbate INDIVIDUAL <br />Q LOCAL AGENCY Q STATE -AGENCY <br />PO B o x 193751 <br />CORPORATION PARTNERSHIP <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #WITH AREA CODE <br />San Francisco <br />CA <br />94119-3765 <br />(415)864-3337 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED <br />✓ box b Micah Q I SELF-INSURED E�j 2 GUARANTEE O 3 INSURANCE 4 SURETYBDND <br />O 5 LETTER OF CREDIT = 6 EXEMPTION ] 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: 1. O II -r] U. a <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />n <br />APPLICANTS NAME (PRINTED S SIGNAT I <br />APPLICANTS TITLE <br />DATE MONTWDAYNEAR <br />John S. Tunger 4 <br />artner <br />LOCAL AGENCY USE ONL <br />COUNTY #// JURISDICTION # FACILITY # bl S,4 L I / <br />It, 3 k <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION <br />FORM A (5-91) <br />DISTRICT CODE -OPTIONAL <br />'6'_1 4 11__15 vr- I q <br />UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \G <br />�giW69A5 <br />