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SOURCES <br /> E <br /> STATE OF CALIFORNIA A �O <br /> STATE WATER RESOURCES CONTROL BOARD w � �¢ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 �n <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE LL <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) l <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Woolsey Oil Cardlock Woolsey Oil ,_Inc . _ <br /> ADD R�SSO I w, G I_r`�1r e r ►, la NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ``�+ W Navy and Fresno <br /> CITY NAME STATE ZIP CODE ITE PHO E# I AR 0 <br /> Stockton CA 95206 �209� 4� - � <br /> ✓ Box <br /> TO INDICATE X_�CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F--] 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR � 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) <br /> Lancaster , Jim (209)948-9412 Eliason Mike (FZ" 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Lancaster , Jim (209)986-9412 Eliason, Mike ( -3A_c50 <br /> DE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Frances & Richard McPherson <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 1501 W Charter Way CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 195206 �(209)941-4934_ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ Woolsey Oil , Inc . <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 166 Frank West Circle CORPORATION 0 PARTNERSHIP COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton ICA 95207 (209)948-9412 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ I4�- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 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 box I or II is checked. <br /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: F] it.E III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLN �NAME &SIG ) PLICANTS TITLE r DAA �ONTpH/DAY YEAR <br /> 41,1 <br /> LOCAL AGENCY USE ONLY 9 <br /> COUNTY# JURISDICTION# FACILITY#3 9-7 <br /> a3(00 - L_-2 3 ► Ig �R <br /> LOCATION CODE OPTIONAL — --- - — — — -- <br /> AL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SI FORMATION ONLY. <br /> FORMA(12 91) FILE THIS FORM WITH TH€LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />