Laserfiche WebLink
.cA-039 lUl Rvx <br /> STATE OF CALIFORNIA W <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD - - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE [D'� <br /> MARK ONLY ® 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATIONE�j ] PER;NIANIENY &SED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE a f <br /> I. FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE COMPL D) <br /> DBA OR FACILITY NAME E OF OPERATOR <br /> Penske Truck Leasing Co., L.P. Environmental Services <br /> ADDRESS ST CROSS STREE PARCEL#(OPTIONAL) <br /> 1950 East Abner Avenue <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205-4554 209 942-2004 <br /> TOINDI AC Box <br /> I�CORPORAnON E71 INDIVIDUAL E::] PARTNERSHIP O LOCAL-DISTRICA gENCV � COUNTY-AGENCY [=STATE-AGENCY O FEDERALAGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(cp imao <br /> 0 RESERVATION f.—/�¢/)yt.(YabC'V. <br /> 3 FARM 0 4 PROCESSOR ® 5 OTHER OR TRUST LANDS 3 _ <br /> - EMERGENCYLO <br /> qDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE AVS: NAME(LAST,FIRST) 209-942-1804 <br /> Jon Foster 916-371-1450 /M PLY r <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE IGHTS: NAME(LAST,FIRST) 7D]-421 s 1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED FE9TjXXXXXYXX — <br /> NAME CARE OF ADDRESS INFORMATION <br /> penLINLeasingCo. L.P. BIG <br /> MAIGORSTREETADDRE ✓ bort bindkak = INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> Route 10, Green Hills, P.O. Box 563 CORPORATION 0 PARTNERSHIP l=COUNTYAGENCV FEDEML-AGENCY <br /> STATE ZIP CODE ONE#WITH AREA CODE �I <br /> Reading PA 19603-0563 610 775-6000 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Penske Truck Leasing Co. L.P. Environmental Servcies <br /> ILING OR STREET ADDRESS INDIVIDUAL STATEADENCV <br /> Route f0, Green Hills, P.O. Box 563 [�CORPORATION = PARTNERSHIP O COU <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> Reading PA 19603-0563 610 775-6000 <br /> tlA 0TTON 0 0 5RA4 EE ACCOUNT NUMBER-Call(916)323-9555 if questions se. <br /> TY(TK) HO 4 4 - 0 0 0 0 5 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bort binEkaN CXI 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O A SURETY SOND <br /> D 5 LETTER OF CREDT 0 6 EXEMPTION O 66 OTHER <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.= I.© 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&WNANATUyREE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> arc E. AZthen j v Envir. Serv. t '/ <br /> LOCAL AGENCY USE ONLY t C - <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL <br /> p a3, L o 000 ?' <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FARM A(5-91) FOR0031AZ <br />