Laserfiche WebLink
STATE OF CALIFORNIA M1° <br /> m <br /> STATE WATER RESOURCES CONTROL BOARD v� , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ._ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F_� 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED.SIT <br /> ONE ITEM a 2 INTERIM PERMIT Q4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Waterloo Food & Fuel Gurpal Sidhu, et. al. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3032 E. Waterloo Rd. Sutro <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209-466-5816 <br /> ✓BOX E3 CORPORATION INDIVIDUAL iX1 PARTNERSHIP 0 LOCAL-AGENCY ®COUNTY-AGENCY° Q STATE-AGENCY° FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> #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 ESERATION <br /> � 1 GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR ® 5 OTHER OR Rol <br /> lA DS 3 CAC 0010817 <br /> 7 6 <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 /> Sidhu, Paul 209-466-5816 <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sidhu, Paul 209-474-3293 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gurpal Sidhu, et. al. <br /> MAILING OR STREET ADDRESS ✓ box to indicate 71 INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 3032 E. Waterloo Rd. ®CORPORATION [X�] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton ICA 95205 209-466-5816 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Gurpal Sidhu, et. al. <br /> MAILING OR STREET ADDRESS be boxto indicate,INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 3032 E. Waterloo Rd. 0 CORPORATION (LJ PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton, I CA � 95205 1209-466-5816 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -l Jill 1 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to mate ® I SELF-INSURED 0 2 GUARANTEE CX 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND <br /> 0 8 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND S CERTIFICATE OF DEPOSIT I }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 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPL ED NDER PENALTYERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED GNATU TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> Keith A. Tall Agent 10/24/98 <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# L <br /> mFm 1111111 , <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> s '�f <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 FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />