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�eeou�Ccy° <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W dam, °o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLIT <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Olilr <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A. Teichert & Son, Inc. Geor e Takemori <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 120 Frank West Circle F Camp Road 193-360-36 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95206 <br /> ✓BOX [ ' CORPORATION INDIVIDUAL a PARTNERSHIP a LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' [] FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #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 BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN I#OF TANKSP.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR M 5 OTHER ORTRUST LANDS 37 <br /> . <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 /> Broaddus, Russ Takemori, George 916-386-6916 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Broaddus Russ 530-677-6239 Takemori. George 916-296-63 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A. Teichert & Son, Inc. Bob Hamel <br /> MAILING OR STREET ADDRESS ✓ Ixxt3 r�.Ca''- [] INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> P.0. BOX 15002 i�CORPORATION = PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento I CA 1 95851 916-484-3011 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A. Teichert & Son, Inc. George Takemori <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> P.O. BOX 15002 " CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sacramento CA 1 95851 916-386-6916 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 0 1117 13 JjN <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE Q 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION ®7 STATE FUND <br /> 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&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: 1.❑ it.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNAAf__C>u <br /> TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> George Takemori - Project Engineer 1 8-11-99 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI <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 THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />