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• • EIV � �q rtSOVP <br /> STATE OF CALIFORNIA Rdi'D''e" cti <br /> • STATE WATER RESOURCES CONTROL BOARD J U 3 <br /> 91 <br /> UNDERGROUND STORAGE TANK PERMIT APPLLCII�� R NTfAL9HEALTtP <br /> COMPLETE THIS FORM FORE H FACILITYISITE <br /> PERMIT/SERVICES <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Federal E;uilding and U.13. —PostGeneral Services Administration <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE Z CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95202 916 551-2684 <br /> TO <br /> / BO TE 0 CORPORATION INDIVIDUAL r7 PARTNERSHIP LO RICTSENCY Il COUNTY-AGENCY STATE-AGENCY J3 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR INDAI RESERVATION #OF TANKS AT SITE <br /> O 3 FARM a PROCESSOR 5 OTHER OR TRUST LANDS 2 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> mar Mike 916 551-2684 Smith Frank 916 551-2684 <br /> NiGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) (415)PHONE#556-1480 WITH _ODE <br /> (415) 556-1480 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> jon <br /> MAILINGOR STREETADDRESS z (GIB OINDIVIDUAL OLOCALAGENCV �STATE-AGENCV <br /> sol I street, ROOM 356 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FK1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacrwnento CA 95814 (916) 551-2684 <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> United States Governinent General Services Administration <br /> MAILING OR STREET ADDRESS box 0Indkme ED INDIVIDUAL E--1 LOCAL-AGENCY O STATE-AGENCY <br /> Sol I Street, Roarn 356 O CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY KI <br /> IFFEDERAL-AGENCY <br /> DE P5IOGbOYY5 zI9Cl�to A 56 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 4 4 -�� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tankowner unless box I or 11'is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGIl E) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> Smith, Frank Asst. Field Office Manag 6 17 <br /> LOCAL AGENCY USE ONLY 'Fr--;)a rz,�4 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION OODE -OPTIONAL CENSUSTRACT# -OPTION* SUPVISOR-DISTRICT CODE -OP <br /> D 1p3 w I 323 <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 /> FORM A(e-BO) <br />