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�v..+. <br /> sou. ef <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W r 2'u <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE mN'' <br /> MARK ONLY F—] t NEW PERMIT 0 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED SITE <br /> ONE REM [::] 2 INTERIM PERMIT 0 4 AMENDED PERMIT E:j 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> The Record Stockton Newspapers Inc. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 530 East Market Street California 149-130-18 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95202 (209) 943-6397 <br /> I/ BOX <br /> TOINDICATE ®CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR 0 RESERVATION INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR E5q 5 OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Steve Peterson 209 546-8249 Rick Henning 209 546-8368 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Steve Peterson (209) 956-9584 Rick Henning (209) 477-8368 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stockton Newspapers Inc. Steve Peterson <br /> MAILING OR STREET ADDRESS ✓ box to Indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 530 East Market Street [CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton I CA 95202 (209) 546-8249 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Stockton Newspapers Inc. Steve Peterson <br /> MAILING OR STREET ADDRESS ✓ box toindicate = INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 530 East Market Street ®CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P`O WI H A E C <br /> Stockton CA 95202 ( � � �4 ` <br /> 6 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate (] 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LD II.0 it.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLYe �, <br /> COUNTY# JURISDICTION# FACILITY# <br /> IT] <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -t7PTIOM4L <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORMA(3/93) 1-0R0033A-R7 <br />