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-Q50JR [ Co <br /> STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD w,�� �,u, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , �,> o <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Idlewild Market Surendra F . Patel <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 3049 W . Hwy 12 DeVreis Road <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lodi CA 95242 209-368-1152 <br /> TO/ BO TE Q CORPORATION E INDIVIDUAL D PARTNERSHIP �LOCAL-AGENCY O COUNTY-AGENCY � STATE-AGENCY � FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR O RESERVATION <br /> F INDIAN #OF TANKS AT SITE E.P.A. I.D.%(optional) <br /> O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS 5 CAC000563256 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Patel Surendra 209-368-1152 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> atel , Surendra 209-368- 1152 PHONE#WITH AREA CODF <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> Surendra F . Patel <br /> MAILING OR STREET ADDRESS ✓ bOx ATU INDIVIDUAL ED COUNTY-GEN � STATE-AGENCY <br /> 507 S o . Cherokee Lane TA CORPORATION Q PARTNERSHIP O PHONE 4 WITH A C FOCERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> odi CA 95240 209-368- 1152 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Surendra F . Patel <br /> .7nEk <br /> MAILING OR STREET ADDRESS box bial# INDIVIDUAL LOCAL-AGENCY DSTATE-AGENCY <br /> 607 S o . Cherokee Lane I�CORPORATION 0 PARTNERSHIP I=COUNTYAGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME 40 209-368-1152 <br /> Lodi CA 952 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bor binftal# E-1 i SELF-INSURED 0 2 GUARANTEE [-1 0 INSURANCE I[D 4 SURETY BOND <br /> I= 5 LETTER OF CREDIT O 6 EXEMPTION [gI W OTHER None <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 PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAVNEAR <br /> Surendra F . Pate p Inner 915/91 <br /> LOCAL AGENCY USE ONLY A (✓ �3GI <br /> COUNTY# JURISDICTION# FACILITY# <br /> 'fel' <br /> LOCATION CODE -OPTIONAL CENSUS TIFACT% -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �T' Z,0 <br /> THIS FORM MUST BE ACCOMPANIED BBCY.ATTLLEAST(1)OR MORE PERMIT APPLICATION-- F'OJRM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR0033A-5 <br /> FORMA(5-91) <br />