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STATE OF CALIFORNIA � •• s <br /> J' A STATE WATER RESOURCES CONTppPLIgg0� qq��p i4 0 <br /> UNDERGROUND STORAGE TANK PERMlTvapp�I �ITION • FORMA <br /> . �. . <br /> COMPLETE THIS FORM FOR EACHrACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT LXJ 3 RENEWAL PERMIT 19,Sid AI NFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT <br /> ❑ 4 AMENDED PERMIT ❑ It TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME Trtno <br /> SCK ASR and SCK RTR ion Administration <br /> BOX <br /> ADDRESS <br /> 5000 Solith Airport Way PARCELa(OPTI)NAL)CITY NAMESITE PHONE 0 WITH AREA CODE <br /> 4772 <br /> TO NOICATE ED CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP ED LOCAL-AGENCY 17:1 COUNTY-AGENCY' Q STATE-AGENCY' IID FEDERAL-AGENCY' <br /> 'x owner d UST Is a pub9c agency,complete the blowing:name of Supemeor of dlv"n,section.DIST <br /> WRICT' <br /> IN eperoles the UST <br /> TYPE OF BUSINESS ❑ ) GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.s to tk q <br /> ❑ 3 FARM ❑ 4 PROCESSOR M—, 5 OTHER ❑ RESERVATION <br /> [� OR TRUST LANDS 2 None <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> BOMANN, DAVE09 487-5327 A INEL LAWRENCE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRSn PHONE a WITH AREA CODE <br /> Dw%y 09"irer (110) 54-3-391710 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> San Joaquin Count <br /> MAILING OR STREET ADDRESS ✓bW bNdktls 0INDIVIDUAL lj LOCAL-AGENCY 0STATE-AGENCY <br /> (�CORPORATION (] PARTNERSHIP ED COUNTY-AGENCY = FEDERALAMNCY <br /> CITY NAME STATE ZIP CODE IONONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILNGO S REETADDRESS ✓ bsablydkaa Q INDIVIDUAL = LOCAL AGENCY ,A�t_1,STATE-AGENCY <br /> 10275 Old Placerville Rd., Ste #16 ED CORPORATION O PARTNERSHIP =COUNTYAGENCY yJ FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> -304 916 551-3406 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- 6 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bybw E-1 1 SELF-INSURED ED 2 GUARANTEE I1 3 INSURANCE O 4 SURETY BOND <br /> =5 LETTER OF CREDIT EV S EXEMPRON =%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.= IL[—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY IY PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> ANTHONY M. RIZZO Environmental Com liance 3/25/94 <br /> LOCAL AGENCY USE CITY Manager <br /> COUNTY a JURISDICTION a FACILITY a <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa-OP NAL SUPVIS -DIS TCODE -fWTA7AW. <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ORMATLON KY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3W) FOROWMA7 <br /> a(a�l9y - <br />