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STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD Wr 4A a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERM NEN YOSE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) Or <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Country Club Exxon New West Petroleum <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2705 Country Club Blvd. Ryde Ave. <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 1 95206 <br /> T Ip NDICATE iM CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> 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 ® t GAS STATION 0 2 DISTRIBUTOR 0 ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptional) <br /> RESERVATION 3 <br /> Q 3 FARM Q 4 PROCESSOR 0 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 /> Moore, Gil (916) 443-0890 Santos, Dolores (916) 443-0890 <br /> NIGH • NAME(LA F1pST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> gore, j11 (916) 443-0890 Santos, Dolores (916) 443-0890 <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> New West Petroleum <br /> MAILING OR STREET ADDRESS ✓ box b Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1831 16th Street Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento 916 443-0890 <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> New West Petroleum <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 1831 16th Street [�l CORPORATION Q PARTNERSHIP Q COUNTY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento I Ca 1 95814 (91 6) 443-0890 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUM ER-Call(916)322-9669 if q es(� tions arise. <br /> TY(TK) HQ 4 <br /> 4-]-10131610161-51_ _ !'�.!' �,� `"t(m(� 6 ;"rn.- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box io indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4SURETY BOND <br /> Q 5 LETTER OF CREDIT Q ti EXEMPTION Off99 OTHER (V <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.= it.M III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> President -7 <br /> LOCAL AGENCY USE ONLY <br /> Oen COUNTY# JURISDICTION# FACILITY#de 20 yd �?/yS n <br />` LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE-OPTrONAL A <br /> V j <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS W A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3193) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU f ORAGE TANK REGULATIONS Fa=3A4u <br />