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c <br /> I 0 <br /> STATE OF CALIFORNIA <br /> � <br /> Ik RNIA w 7 <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .� . <br />'I COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br /> MARK ONLY 7 1 NEW PERMIT r7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL <br /> ONE ITEM E] 2 INTERIM PERMIT = 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> California Water Service <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1602 E. Lafayette St. Wilson Way <br /> f CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton,- CA 95203 (209)464-8311 <br /> ✓BOX CORPORATION (] INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' D STATEAGENCY' 0 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 a 1 GAS STATION E= 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.It(optional) <br /> RESERVATION CAL000046942 <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST)Scott (209WITH <br /> 464E8331 DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Bailey, Scott (209)464-8311 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE CAM PLFTFA) <br /> NAME CARE OF ADDRESS INFORMATION <br /> California Water Service <br /> MAILING OR STREET ADDRESS ✓ bcx to i dca'a INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 1602 E. Lafayette t• CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> r <br /> Stockton, CA 95203 (209)46488311 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF,, awrifornia Water Service CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate Q INDIVIDUAL C] LOCAL-AGENCY STATE-AGENCY <br /> 1602 E• Lafayette ST• CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> Stockton, C ICA 95203 (029)464--8311 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <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 0 5 LETTER OF CREDIT O 6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 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. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF R v O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TAN NER'S TITLE DATE MONTHiDAYNEAR <br /> California Water Service By L Contractor 11/13/00 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m o � <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 /> O1 jWNERyM7 UST FILE THIS FORMS HE LOCAL AG/E�N�C�Yj IMPLEMENTING TH`HEEUNDERGROU19ORAGE TANK REGULATIONS <br /> FORMA(6-95) .'./s;,ii4 <br />