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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ®, :> <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ; . , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE le - <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ift, PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) ' <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Eastland Plaza Hen#ry Barkett <br /> ADDRESS I - NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> 678 North Wilson Way Oak street <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 195,204 209 951 -579 <br /> ✓ BOX [5+�RPORATON CD INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' a STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 6 ownarol USTis a pebkapmy.m Tele me following.nameelsW rntorddNision,sedlonwotrrawhiimoperalnme UST <br /> TYPE OF BUSINESS Q i GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opllon#I) <br /> RESERVATION <br /> ❑ 3 FARM ❑ A PROCESSOR 5j3j 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAIrE( T.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Eastland Plaza Hend et <br /> MAILING OR STREET ADDRESS ✓ bot b PTD <br /> bdul# Q MOUAL (] LOCA4AGENCY STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAM STATE ZIP CODE PHONE Y WITH AREA CODE <br /> CA 95204 209 951 -5787 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot to hdAal <br /> wDNIOUA t OLOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP CD COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAFE STATE ZIP CODE PHONE 9 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ W 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓W.to kzcale E] I SELF-INSURED Q 2 GUARANTEE CD 3 INSURANCE ED 6 SURETYBONO :) 5 LETTER OF CREDIT O 6 EXEMPTION IED T STATE FUND <br /> O8 STATE FUND SCHIEF FINANCIAL OFFICER LETTER =9STATE FUND&CERTIFICATE OFITEIT O10LOCAL GOVT.MECHANISM O99OTHER <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.E] H.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINT //A TANK OWNER'S TITLE DATGE MONTHIDAWYEAR <br /> m- O dc <br /> LOC L AGENCY USE ONLY <br /> COUNTY# JURISDICTION a ACILITY a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT1ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS S tS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6.95) OWNER MUST FILE THIS FORM VWHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUORAGE TANK REGULATIONS <br />