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0 STATE OF CALIFORNIA , 0 6 n <br /> STATE WATER RESOURCES CONTROL BOARD �'` . ti <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ~; ,r a� <br /> • Cit l�Oti Nor <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> D OR F CILITY NAME NAME OF OPERATOR <br /> l SS#31010 Darrell Eppler <br /> S NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> 2701 West March Lane 1-5/March Lane <br /> CITY NAME STATE I ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 952070000 2094737337 <br /> BOX ® CORPORATION ❑INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL-AGENCY ❑ COUNTY-AGENCY <br /> ❑ STATE AGENCY ❑FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> 'If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR❑ 5 OTHER RESERVATION 3 <br /> 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 /> Darrell Eppler 2094737337 <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME:(LAST,FIRST) PHONE#WITH AREA CODE <br /> Darrell Eppler 209/473-7337 <br /> II. PROPERTY OWNER INFORMATION-MUST BE COMPLETED <br /> AME CARE OF ADDRESS INFORMATION <br /> srn Corporation <br /> MAILING OR STREET ADDRESS Jba.m-.i.— []INDIVIDUAL <br /> ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> P.O. Box 52085 ®CORPORATION []PARTNERSHIP <br /> ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE <br /> Phoenix AZ 85072 (602)437-0600 <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME CARE OF ADRESS INFORMATION <br /> Tosco Corporation Environmental Com liance <br /> MAILING OR STREET ADDRESS J box to indicate []INDIVIDUAL ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> P.O. Box 52085 0 CORPORATION ❑PARTNERSHIP ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> Phoenix AZ 85072 (602)437-0600 <br /> 9v. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916) 322-9669 if questions arise. <br /> (TK) HQ 4 40 3 6 2 4 4 PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br /> J box to indicate ® 1 SELF-INSURED ❑ 2 GUARANTEE ❑ 3 INSURANCE ❑ 4 SURETY BOND <br /> ❑ 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 I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L ❑ 11. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> DON EVERSON DIRECTOR OF COMPLIANCE APRIL 1, 1997 <br /> LOCAL AGENCY USE ONLY 710 <br /> COUNTY # JURISDICTION # FACILITY# J.; <br /> Kil ENraw' <br /> LOCATION CODE-OPT/ONAL CENSUS TRACT X-OPT/ONAL 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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS. <br /> FORMA 13/931 � � FOR0033A-R7 <br />