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0 <br /> STATE OF CALIFORNIA +. ° <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER Y CLOS D.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q s AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> R,Cltc's C KWROO c 4,' GOND Z A%L5�17 <br /> ADDRESS 8 47 f_ 0 �W E 9- SRAM� P10. NEAREST CROSSSTREETL��A46 PARCEL a(OPTIONAL)CITY NAME IP STATE 23P ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOCK-TON I CA `75 ?,09 2 -g—n-09 q- <br /> ✓ Box Q CORPORATION 5Kr INOMDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY` Q STATE-AGENCY` Q FEDERAL-AGENCY` <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a pubfxt agency,complete the tolowing name at supervisor of division,section or offm which operates the UST <br /> TYPE OF BUSINESS :1v' 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.O.#(optional) <br /> J� RESERVATION <br /> Q 3 FARM Q d PROCESSOR Q 5 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 /> RICK OW ZAL15 5 Z 4-'1-1 -34- ($ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G GoION7,4�,Le6 (24>9) 41--7'1-3Y619 <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAR(�G) � S"1/7 A ��1\ I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 60x10#Af=8 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> G8-7 AJ—r CA N A Q CARPoiATION Q PARTNERSHIP Q CO Rm-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> -WRLock. , CA 95380 CA , 9 S 38a 63 z—99 38 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> RI <br /> D L"' <br /> MAILING OR STREET ADDRESS +� be box tolndicate NDMDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> p$ ,(oO LOWER 1c,DA <br /> (e =coN'ORATION Q PARTNERSHIP Q COUNTY-AGENCY (Q FEDERAL-AGENCY <br /> CITY NAME STATE LP CODEPHONE#WITH AREA CODE <br /> S-1-oCk-'1'0N. CA 9S Z© Ze7-7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- -1 1 1 1 1711 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE j',;&3 INSURANCE Q e SURETY BOND Q 5 LETTER OFCREDIT 716 smarnON I=J 7 STATE FUND <br /> Q 8 STATE RIND E CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND 6 CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 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.= 11.= III. <br /> 6�pLjcAar THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> �T� TANK✓moi NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> M I I 12 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 2 iG o <br /> LOCATION CODE •OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR.DISTRICT CODE .OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT Lc-AgT(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR**THE LOCAL AGENCY IMPLEMENTING THE UNDERGROA�ORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />