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eyou-ccs <br /> • STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD 3 dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLYCLOSED <br /> ONE ITEM EJ 2 INTERIM PERMIT 0 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION - UST BE COMPLETED) <br /> BA OR FACILITY NAME NAME OF OPERATOR <br /> Nella Oil Co 427 Cardlock Nella Oil Com an <br /> MESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3300 Waterloo Rd . <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 ( 209) 462-3107 <br /> ✓BOX Q CORPORATION 0 INDIVIDUAL CM PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,compiete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER ORTRUSTLANDS 7 <br /> 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 /> NAME CARE OF ADDRESS INFORMATION <br /> Nella Oil Company (same as mailing address) <br /> MAILING OR STREET ADDRESS ✓ box to nd¢ate 0 INDIVIDUAL <br /> Q LOCAL-AGENCY Q STATE-AGENCY <br /> 2349 R i c k e n b a c k e r Way O CORPORATION EX PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Auburn , CA 95602 1 (916) 885-0401 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Nella Oil Company (same as mailing address) <br /> MAILING OR STREET ADDRESS ✓ boxioindicate <br /> a INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 2349 R i c k e n b a c k e r Way 0 CORPORATION [ PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Auburn , CA 1 95602 (9 16) 885-0401 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 - 0 0 1 8 9 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> O 8 STATE FUND 3 CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 3 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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.[::] it.Pi iF III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER E PRI ED& G ATURE) TANK OWNER'S TITLE DATE MONTHiDAYIYEAR <br /> Thomas A. D elle Partner 1 8-14-97 <br /> LOCAL AG6CY USE ONLY E4c 17/ <br /> COUNTY# JURISDICTION# FACILITY# <br /> IE � 03 (d0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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-T-H�IIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGUL�AyTIONSQ. <br /> FORMA(5-95) � � �-7 <br />