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E" <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA s. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT = 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 1laterl©a Food At Fuel Gur al Sidhu t <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3032 E. Waterloo Rd. -, <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209--466-5816 <br /> ✓BOX CORPORATION Q INDIVIDUAL (r PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE 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 a 1 GAS STATION 0 2 DISTRIBUTOR 0 RESERIF <br /> #OFTANKS AT SITE E.P.A. 1.13.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 'CAC 001081776 <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 /> 3idha Paul 209-466-5316 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9idhua Paul 209-474-3293 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> "r al Sidhul et, r l <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 3032 EM Waterloo Rd. =CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 3urpa al. <br /> MAILING OR STREET ADDRESS a ✓ boxto indicate INDIVIDUAL D LOCAL-AGENCY Q STATE-AGENCY <br /> loo Rte. =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> :,Aockton, n <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- <br /> - <br /> j V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE 0 4 SURETY BONG =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> D 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OE-PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTEDNATU ` TANK OWNERS TITLE DATE MONTHIDAYNEAR <br /> Kith A. 'Pall Agent 10/24/9€ <br />{ LOCAL AGENCY USE ONLY '� <br /> COUNTY# JURISDICTION# FACILITY# <br /> F FT ❑ <br /> f LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br />(' ' <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#THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUHQ STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />