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S <br /> • P�6�VR - C <br /> STATE OF CALIFORNIA A <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD 3 o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a <br /> 0 <br /> •C�(IfOM N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__] 1 NEW PERMIT 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. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Waterloo Food & Fuel Gur al Sidhu <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3032 E. Waterloo ]Rd- q1]f:-r0 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209-466-5816 <br /> ✓ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL E�3t PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS 2 CAC 0 01 0 81 7 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) <br /> MNU(L I 4Q A E AM ARA I& NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA GODE <br /> Sidhu, <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sidhu ef—al- <br /> MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 3032 E. Waterloo Rd. CORPORATION EM PARTNERSHIP [] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton A 95205 209-466-58t6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Gur al Sidhu et.al. <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 3032 E Waterloo R CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4]_1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate iX 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 1:715 LETTER OF CREDIT 0 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.[] II.® III.0 <br /> THIS FORM HAS BEEN COM UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SI ATUR APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> Keith A. Tal is Agent 9/27/99 <br /> 0-1 <br /> LOCAL AGENCY USE 0 Y <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3T I i I] <br /> LOCATION CODE -OPTIONAL CENSUS -OPTIONAL SUPVISOR&STRICT D -OPTIONAL <br /> L., ® o 0) <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 /> FORM A(5-91) FOR0033A-5 <br /> �o�q/av <br />