Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA 0 <br /> �} COMPLETE THIS FORM FOR EACH FACILITY/SITE 4,i-Ola <br /> MARK ONLY Ld a 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY OSEO On <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <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 95206 <br /> I/ Box TO DIC TE 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 © 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.9(optional) <br /> ESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER ORTRUSTLANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE It 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(L F ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> oore, i� (916) 443-0890 Santos, Dolores (916) 443-0890 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> New West Petroleum <br /> MAILING OR STREET ADDRESS ✓box to 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 /> III. 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 Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1831 16th Street ( CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento Ca 95814 �(916) 443-0890 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUM ER-Call(916)322-9669 if q estions arise. <br /> TY(TK) HO 4 4- - ©13 1 bl6l� �u �',� A�r� 6 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 0 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Pff 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.E II.u 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 DATEMONTWDAY/NEAR <br /> President 7—/ S--71s <br /> LOCAL AGENCY USE ONLY <br /> O��Q COUNTY# JURISDICTION# FACILITY#,A0zo o -Z�, <br /> a 13 0 17 .2 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SILPVISOR-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 REGULATRW <br /> FORM A(3193) FOROM3A-R7 <br /> 6 0 <br />