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STATE OF CALIFORNIA <br /> FORM `A': WATER RESOURCES CONTROL BOARD <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION (� <br /> ONE ITEM ® 7 PERMANENTLY CLOSED SITE <br /> ❑ 21NTERIM PERMIT ❑ Q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION a&ADDRESS— (MUST BE COMPLETED) � <br /> FACILITY/SITE NAME N <br /> Sullivan & Mann Lumber Co . CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> 16177 S o . McKinley NEAREST CROSS STREET ✓Boxlalntl le PARTNERSHIP ❑ STATE AGENCY <br /> Louise A V e COAPOMTION ❑ lO LAGEN ❑ FEDEA bpGEN <br /> CITY NAME ❑ INOIVIpDAI COUNT"AGENCY <br /> Stockton STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 95330 209-858-4737 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ q PROCESSOR ✓Box iI INDIAN EPA ID # <br /> 1 GASSTATION ❑ 3 FARM RESERVATION or #of TANK's <br /> )`' SOTHER TRUSTLANDS ❑ CAC 000559176 ATTHISSITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Mann Mike209-858-4737 PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST( PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Mann Mike PHONE#WITH AREA CODE <br /> 209-858-4737 , <br /> II. PROPERTY OWNER INFORMATION 81 ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> Morton Sullivan CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate PARTNERSHIP <br /> PO BOY. 4 5 7 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYCITY NAME ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Jackson CA 95642 209-223- 1676 <br /> III. TANK OWNER INFORMATION St ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> Morton Sullivan CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box(o indicate )(I$ PARTNERSHIP ❑ STATE-AGENCY <br /> PO BOX 457 ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE#.WITH AREA CODE <br /> Jackson CA 95642 209-223- 1675 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE II)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Ej 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 8 SIGNATURE) <br /> DATE <br /> X Morton Sullivan 2/ 1 /91 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID If <br /> If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME <br /> �. \�� 1 PHONE#WITH AREA CODE <br /> (10 <br /> PERMIT NUMBER PERMITAPPROypI DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> O DATE FILED <br /> YES E] NO <br /> CHECKp PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPTpblas <br /> BY: I/l <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE I)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS�LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A FOR M <br /> I ,_/ 2� DATA PROCESSING COPY <br />