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4 STATE OF CALIFORNIA �O <br /> STATE WATER RESOURCES CONTROL BOARD mom, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> PER E ED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> A. Teichert & Son, Inc. George Takemori <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 120 Frank West Circle -3 6 0 <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> Stockton CA 195206 <br /> ✓BOX ®CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY 1-7 COUNTY-AGENCY' 71 STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> N owner of UST is a public agency,cornolete the following:narne of swervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS F7 1 GAS STATION 0 2 DISTRIBUTOR = <br /> ✓fF INDIAN N OF TANKS AT SITE Iz P.A- 1.D.#(optional) <br /> RESERVATION <br /> a 3 FARM a 4 PROCESSOR [M 5 OTHERT OR TRUST LANDS 3 <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 /> Broaddus , Russ Takemori, George 916-386-6916 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Broaddus Russ 530-677-6232 Take-mori. Gp.Qrge 916- . <br /> 96-6 319 <br /> I1. PROPERTY OWNER INFORMATION-(MUST RE(OAAPLFTRnj <br /> NAME CARE OF ACOMESS INFORMATION <br /> A. Teichert & Son, Inc. , Bob Hamel <br /> rL:JUNa OR STRFET A�CPclnj�3 i -✓V r'.. - '7.�,.,,....,y.t- .f _ r� j7A"CaGE?IrY <br /> P.O. BOx 1 5 V 0 2 _ C ErS+tP �.. .._..:'! �1 _.._..AL <br /> -AGE CY <br /> N PARTTI <br /> CITY NAME !STATE ZIP CODE PHONE u WITH AREA CODE <br /> _Sacramento I CA 95851 1916-484-3011 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AOORESS INFORMATION <br /> A. Teichert & Son, Inc. Georcie Takemori <br /> MAILING OR STREET ADDRESS ✓ box to ndcte Q INDIVIDUAL C:j LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 15002 [XJ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAME STATE , ZIP CODE PHONE 11 WITH AREA CODE <br /> Sacramento I CA ! 95851 916-386-6916 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 0 1. 7 3 8 5_ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to aW rate I SELF 11SURED CD 2 GUARANTEE Q 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION LM T STATE FUND <br /> Q a STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND d 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: I.a it.Q III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED$SIGNATUpp TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> George Takemori -- cwt,- Project Engineer 18-11-99 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 0 JURISDICTION N FACILITY N <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 /> OW:dEA MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNIIIIIIIII1111110RAGE TANK REGULATIONS <br /> FORM A(6.95) }�' S <br />