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STATE OF CALIFORNIP WATER RESOURCES CONTROL ARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FV <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Idlewild Market <br /> ADDRESS NEAREST GROSS STREET NTION PARTNERSHIP <br /> [] CRPORAClClOCAL <br /> AGENCY ❑ fENERALAG ND <br /> 3049 IPJ . Hwy 12 D e V r e i S Rd [EX I [IrY COUNAGENCY <br /> STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> CITY NAME <br /> Lodi CA 95242 209-368- 1152 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID n q 01 TANK'a <br /> RESERVATION or ❑ CAC 000563256 AT THIS SITE 1 <br /> ® 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Patel , Sunny 209-368-1152 <br /> NIGHTS: NAME(LAST,FIRST) PHONE q WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Patel , Sunny 209-368- 1152 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SUnn Patel <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ClSTATE-AGENCY <br /> CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 3049 W . Hwy 12 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> Lodi CA 1 95242 209-368-1152 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sunny Patel <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Wyly CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3049 W . HINy 12 INDIVIDUAL ❑ COUNTYAGENCY <br /> CITV NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> Lodi CA 95242 209-368-1152 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ® 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) - —[77 <br /> Sunny Patel ,< 3/8/91 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IN JURISDICTION M AGENCY q FACILITY ID M If of TANKS at SITE <br /> 3 ( I 15 1 1 1 1 O <br /> CURRENT LOCAL AGENCY FACILITY IDM LAPPROVED PHONE N WITH AREA CODE <br /> IDLEW 3D <br /> PERMIT NUMBER PERMIT APPROVAL DATEIT EXPIRATION DATE <br /> LOCATIQLI DE CIENNSUUSSTRACTCTM SUPERVISOR-DI NESS PLAN FILED DATE FILED <br /> (J1fLJIVO TFYES [] NO [] <br /> CHECK M PERMIT AMOUNT SURCHARGE AMRECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />