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STATE OF CALIFORNIA <br /> STATE,WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION;-.CORM Awn <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY E� 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM 0 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 /> Waterloo Food & Fuel 7idh <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3032 E. Waterloo <br /> Rd- <br /> CITY NAME STATE ZIP CODE SITE PHONE o WITH AREA CODE <br /> Stockton CA 95205 209-46§-58-16 <br /> ✓ BOX <br /> TO INDICATE D CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORIF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> J RES✓ERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS ' CAC001 081776 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> OftPHONE It WITH AREA rnD;=I (LAS Ig5TY # ARA NIGHTS: NAME(LAST,FIRST) <br /> PHONESidhu, „ .._� <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> I NAME CARE OF ADDRESS INFORMATION <br /> Sidhu at- i <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> 3032 E. Waterloo Rd o CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION 7 <br /> Gur c” l SiCa.)'11 k-,a...a1• s <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY ` <br /> 3032 E Water1400 Rr` Q CORPORATION PARTNERSHIP COUNTY-AGENCY C] FEDERAL-AGENCY <br /> i CITY NAME STATE ZIP CODE =PHONE,#WITH AREA CODE <br /> s <br /> `IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT []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: I- IL ] III. <br /> THIS FORM HAS BEEN COMPLETEqUNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&S TUR - APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> 'eatthA. Tal a agent 9/27/99 <br /> u <br /> LOCAL AGENCY USE 0 'Y <br /> COUNTY# JURISDICTION# FACILITY# <br /> � a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(4)OR.IIIIORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ' FORM A(5-91) e <br /> FOR0033A-5 <br />