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,.Fi#�'> r rad. •^ - ,. r .+Rs. '1!g ->✓. - <br /> csou�ees <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT r7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY C <br /> ONE ITEM =12 INTERIM PERMIT 0 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 /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3300 Water'Loo Rd . <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 9520.E (209) 462-3107 <br /> ✓BOX Q CORPORATION E�J INDIVIDUAL [= PARTNERSHIP (]LOCAL-AGENCY 0 COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'B 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 BUSINESSt GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <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 /> Cruse Patrick 408 294-9110 Rhoades Jack 916 885-0401 <br /> NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Cruse, Patrick (408) 462-2114 Rhoades Jack 916 783-9928 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Vella Oil Company (same as mailing address) <br /> MAILING OR STREET ADDRESS ✓ box to indcate 11 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 2349 R i ek e n b a c k e r W a D CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Auburn, CA 95602 (916) 885-0401 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> I Nella Oil Company same a mail ' n . addres <br /> MAILING OR STREET ADDRESS ✓ box to indicate ED INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 2349 R i c k e n b a c 'Way (�CORPORATION ARTNERSHIP [�COUNTY-AGENCY.. :Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP RIEFE PHONE#WITEkA CODE <br /> Auburn,, 95602 <br /> IV.BOARD`OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4 4- -10 10 111 9 8 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 11 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4,SURETYBOND =5 LETTEiflOF CREDIT =6 EXEMPTION 0 7 STATE FUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE RIND&*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 A",VF DRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.a III.a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER NAME,(PONTED& N TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> Thomas A. D eUe � Partner 8-14-97 <br /> LOCAL AGENCY USE ONLY \74- <br /> _j, ;L--"j & <br /> COUNTY# JURISDICTION# FACIL #' <br /> 7- 3 7 13[131 qg <br /> LOCATION DE PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR•DISTRICT CODE -OPT! NA <br /> THIS FORM UUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> i <br /> OWNER MUST FILE THIS FORMdWH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU STORAGE TANK REGULATIONS <br /> FORM A(6-95) Y <br /> 0/ ccs '— <br />