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esoun es <br /> STATE OF CALIFORNIA : " o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> • C�(iFo�N� <br /> COMPLETE THIS FORM FOR <br /> � E <br /> EACH FACILITYISIT <br /> MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT yl 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT L] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> B"�"' �e ��le��, — - - (3o eff e'fn�leu <br /> ADDRESS NEAREST bROSS STREET PARCEL#(OPTIONAL) <br /> 419 South Main Street Wetmore <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 200, 239-7978 <br /> ✓ Box <br /> TO INDICATE CORPORATION = INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® I GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> i� 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS ICAC001222584 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 209) 54 5 -111 Z <br /> ba�3Q_ tt _ _ 2_09 -545--t i LZ Co,I '-1� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) Cztj)) -S'13-0 1 Z O <br /> e. lug - S7S-44 C 1 Q# PHONE#WITH AREA CODE <br /> J <br /> It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME s, CQuye�` CARE OF ADDRESS INFORMATION <br /> % —71 <br /> MAILING OR STREET b <br /> ADDRESS p Q ✓ box indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> _ R o , nuX. 1 U// CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE#WITH AREA CODE <br /> Sul. Cft 9SW Z09)-S`fS-Ir ZZ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> —s-I C I A D ---6 f+ G" I <br /> MAILING O STR ET ADDRESS ✓box to indicate INDIVIDUAL <br /> OLOCAL-AGENCY STATE-AGENCY <br /> P,0. 6."( 109 9 CORPORATION a'PARTNERSHIP [7:1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> co 9S392v9)—sys-►(zz <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ �414 - o LzI 91Q]S_ItJ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box to indicate I 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 7] <br /> 11 5 LETTER OF CREDIT 0 6 EXEMPTION CJ 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: I.F] II.>< 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&SIGNATURE) APPLICANTS TITLE DATEMONTH/DAY/YEAR <br /> aL 6 2 V. P. Ill <br /> Z 10 96 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 R 31 � 2 1 4 1 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS `�a3_ <br /> F0 033A <br />