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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Y31 <br /> UNDERGROUND STORAGE TANK PERMIT APPLI RM A � oe <br /> uI Z�' r•I,nOYY.Y <br /> COMPLETE THIS FORM FOR EACH FACILIrYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> CONNE M NNFI I MOTOR TRACK CO. I <br /> A�DDDRRE.ISS'1 NEAREST CROSS STREET LA(ONC <br /> PTpNAL) <br /> ImI <br /> CITY 11 <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 5700 CA 95205 1(209) -948-3434 <br /> L <br /> TOINDICATE `XI CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCALCGENCY Q COUNTY-AGENCY Q STATEAGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESSt GAS STATION �--I 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS AT SITE E.P.A. 1.D.N IoPIm 0 <br /> LJ PESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY 66NP&PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) �2Q9 T 948-3434 <br /> HECISMAN.SHEL - WaLiFi� Phil DNELYuiB:eeepCODE <br /> NIGHTS: NAME(LAST.FIRST) PH N WITH AREA CODE NIOHTS: ME(LAST,FIRST) <br /> HECKMAN SHELDON 209 952-1675 <br /> it. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CO.NNELI_MOTOR TRHCK_GO. mac N NDIVDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> MAILING OR STREET ADDRESS Q <br /> P-_ 11 80"46) 6111 CORPORATIONQ PARTNERSHIP Q COUNTY-AGENCY AC FEDERAL AGENCY <br /> pTE ZIP CODE PHONE N WITH AREA CODE <br /> STOCKTON CA. 95208 209 948-3434 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> CONNECTOR TRI .-K_CO__ INC __ ✓ box Moak,. <br /> AN <br /> MAILING OR STREET ADDRESS Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> P__(I BOX RGEfy ____ CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME !— STATE ZIP CODE PHONE N WITH AREA CODE <br /> STOCKTON CA. 95208 209 948-3434 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Calf(916)323.9555 if questions arise. <br /> TY(TK) HO <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ 6ox bMalkale Q I SELFINSURED M'2 GUARANTEE 4� 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It Is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.L-I III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTEDA APPLICANTS TITLE DATE MONTHMAYNEAR <br /> SHELDON HECKMAN SIGNATU :) PRESIDENT 3117/93 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION# FACILITY« - <br /> El I I <br /> LOCATIONCODE -OPNONAL ICEfJSUSTRA60 -OPTIONAL 3UPVI50R-DISTRIC CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM S,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WR ' E LOCAL AGENCY IMPLEMEN NG�J HE UNDERGROUND STORAGE TA K REGULATIONS FgIW73A R6 <br /> N Z_ AAA 5 7cX 2-a � <br />