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pie °" e <br /> STATEOFCAUFORMA —��` c��^ <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA,, <br /> PERPnt i/SERVICE ' �.�,.'a�' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT ® 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 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 /> 2168 Robert James Parkinson <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Charter Way Lincoln <br /> ITYNAMEW. STATEZIP H WI CODE <br /> Stockton CA 9526 5 M!'Mr <br /> TOINDICATE -1 CORPORATION ®INDIVIDUAL I=PARTNERSHIP LOCAL AGENCY O COUNTY-AGENCY D STATE-AGENCY E FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS , GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TA AT SITE E.P.A. I.D.#(OpharMl) <br /> RESERVATION C CAL 000 048 685 <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS �f <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 8 0 U- <br /> Parkinson, Robert 209-943-0286 Arco Maintenance PHONE a WITH AREALODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-634 9 <br /> Arco Maintenance 800-272-6349 Arco Maintenance <br /> PHONE#WITH AREA Coop <br /> fl. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Frank H. & Rose V. Rodgers Frank H. & Rose V. Rodgers <br /> MAILING OR STREET ADDRESS ✓ box binOkab INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 1321 S. Lincoln St. CORPORATION ® PARTNERSHIP Ll COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREACOCE <br /> Stockton CA 195206 209-464-1146 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ bw biWkab INDIVIDUAL O LOCAL-AGENCY ED STATE AGENCY <br /> 17315 Studebaker Rd. IX CORPORATION O PARTNERSHIP O COUNTY-AGENCY I=FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER.Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41 4 d 01 01 51016 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bw bIntlkateSELF-INSURED (]2 GUARANTEE =3 INSURANCE I�4 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION E-:I 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: 1.0 11.F7 III.E:y <br /> THIS FORM HAS BEEN COMPLETED UNDER PENA TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> Consultant B.C.E.In 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY <br /> x ), q Lf JURISDICTION# FACILITY/ <br /> LOCATION CODE -OPT1O(UL CENSUS TRAnOP NAL SUMVJ§OR_-DISTRICT CODE -OPTIONAL -yl1 v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE�SITE INFORMATION ONLY. <br /> FORMA(S91) FOR0033A5 <br /> Preparers Barghausen '^nsulting Engineers Inc . ; <br /> 4612 Roseville Rd . , Berth Highlands , CA 95660 <br /> 18215 72nd Ave . South , Kent, WA 98032 <br />