Laserfiche WebLink
0 <br /> A 4� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> REU0_% t;jY9QD STORAGE TANK PERMIT APPLICATION•FORMA <br /> OCT 13 1999 COMPLETE THIS FORM FOR EACH FACILrI7Y1SITE <br /> MARKF0h[y1R(MML�4T"m,HEALT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEMPEWIT 1N8T?RqQFzS E] 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 777 NAME OF OPERATOR <br /> DBA OR FACILITY NAME GUY al Sidhu L) <br /> Waterloo Food & Fuel NEAREST CROSS STREET FAM"L N(VV I IONAL) <br /> T <br /> ADDRESS <br /> Q RC� -S AREA c(:Me <br /> #�WITH JA <br /> 3-03-2 E. STATE ZIP CODE SITE PHONE�#WITH AREA CODE <br /> CITY NAME CA 952. 20 _5 <br /> 9=4 -S8 6 <br /> Stockton, 0 E E L <br /> I/ BOX LOCAL-AGENCY 0 COUNTY-AGENCY F__j STATE-AGENCY 0 FEDERAL-AGENCY <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS ✓ IF INDIAN r#OF:TANKS AT OF E.P.A. I.D.#(optional) <br /> TYPE OF BUSINESS f�,� 1 GAS STATION E:] 2 DISTRIBUTOR ED RESERVATION <br /> W- 5 OTHER FOR TRUST LANDS CAC001 081776 <br /> 3 FARM Fj 4 PROCESSOR <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE-A-willi-AREA-CME <br /> RAU NIGHTS: NAME(LAST.FIRST) I-- WITU An <br /> Es ' L I I Ir TIN In I n rk n <br /> Tl <br /> PROPERTY OWNER INFORMATION-(MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> S <br /> NAME <br /> �_e x,.WW'c,. E:] IOU STATE-AGENCY <br /> 3-urpal---S _dh box to WiCate INDIVIDUAL CD LOCAL-AGENCY <br /> CORPORATION <br /> 10 A NCY <br /> MAILING OR STREET ADDRESS loo PARTNERSHIP <br /> COUNTY-AGENCY ED FEDERAL-AGENCY <br /> ED CORPORATION PARTNERSHIP <br /> ITA'TE -TP_Hoid_E AREA CODE <br /> 3032 E. Waterloo Rd. T"TC Z"" i A <br /> ZIP CODE <br /> CITYNANIC: 6 5 <br /> Stockton <br /> Ill. TANK OWNER INFORMATION <br /> ST BE COMPLETED) <br /> CARE OF CARE INFORMATION <br /> NAME OF OWNER <br /> Gurrial Sidhu et.al. ted <br /> I/ box iD indicate INDIVIDUAL LOCAL-AGENCY [�j STATE-AGENCY <br /> _WAi_I­NGOR­S_TRE)E_T ADDRESS [:j CORPORATION PARTNERSHIP COUNTY-AGENCY E] FEDERAL-AGENCY <br /> a2 <br /> ZIP C <br /> 3 22i STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> -IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4gE= <br /> -FT <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ 00 SELF-INSURED 02 GUARANTEE 0 3 INSURANCE []A SURETY BOND <br /> box to Indicate F__3 5 LETTER OF CREDIT 0 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or 11 is checked. <br /> GHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.K] III'D <br /> THIS FORM HAS BEEN COM UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE,IS TRUE AND CORRECT <br /> ......Ju""'4"L' THE <br /> APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> Keith A. Tal is Agent <br /> 9/27/99 <br /> APPLICANT'S NAME(PRINTED&S ATUR <br /> Agent <br /> F Y <br /> LOCAL AGENCY USE 0 <br /> COUNTY# JURISDICTION# FACILITY# <br /> [I] F-1:1= <br /> [_LC60_C7AT_0NCODE -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS M MUST BE ACCOMPANIED PAILT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONt Y. <br /> All <br /> FORM A(5-91) 14P <br />