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4 _ <br /> .. ` r ... <br /> E OunctS <br /> STATE OF CALIFORNIA A�P <br /> STATE WATER RESOURCES CONTROL BOARD W , o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA rs . o= <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> •C�I.f OR N.� <br /> y, <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 1:1 2 INTERIM PERMIT Q 4 AMENDED PERMIT a 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 Gur al Sidhu et. al. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> '1132 E. Waterloo Rd. S t <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 195205 209-466-5816 <br /> ✓BOX Q CORPORATION (] INDIVIDUAL ® PARTNERSHIP (] LOCAL-AGENCY a COUNTY-AGENCYSTATE-AGENCY` FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '8 owner of UST is a public agency,complete the following:name of supervisor of division,sedan or office which operates the UST <br /> TYPE OF BUSINESS a 1 GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS CAC 001 081776 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sidhu Paul3ML466-5816 <br /> NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> Sidhu, ,Pau? 209-474-3293 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> fur ,l Sidhu et. al <br /> MAILING OR STREET ADDRESS ✓ box to indicate [:1 INDIVIDUAL E:] LOCAL-AGENCY (] STATE-AGENCY... <br /> E. Waterloo Rd. CORPORATION 91PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCYY" <br /> CITY NAME STATE 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 /> .�urPal Sidhu, et. al. <br /> MAILING OR STREET ADDRESS &e boxtoindicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 3032 E. Waterloo Rd. (]CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> _j CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED = 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION [=1 7 STATE FUND <br /> 0 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 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 O ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED GNATU TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> § eith A. mall Agent F % /98 <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> ELI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#,•OPn[)(vAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 FORAO ' 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO S-TOR4GE TANK REGULATIONS <br /> FORMA(6-95) �� vC-'� _ �+� �`'Ea/K.✓ <br />