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Of 00 �yOURCCS <br /> STATE OF CALIFORNIA APP °oti+ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �s . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t <br /> �• ,.o m <br /> MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT -*5<5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SI <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME North Stockton Auto Servic NAME OF OPERATOR Ed Niemann <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 8709 N. Davis Rd. <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton, CA 95209 (209)478-1614 <br /> ✓ BOX ED CORPORATION 25 INDIVIDUAL E] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCYFEDERAL-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 RESEIF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR E:N 5 OTHER OR TRUST LANDS 1 CAL 000042157 <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 /> Niemann, Ed (209)478-1614 Niemann Ed (209)478-1614 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Niemann Ed (209)478-1614 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFT1=I71) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Niemann Ed <br /> MAILING OR STREET ADDRESS ✓ bcx b .ca: E4 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> R70A N- Davis Ed CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA I CA � `5209 � (209)478-11(314 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Niemann, Ed <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> 8709 N. Davis Rd. =CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED ED 2 GUARANTEE F7 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> O 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 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 WC ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> TH S B OM LET U R PENAL.TY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAIVE(PRINT D&SIGNATURES Char horpe TANK OWNER'S400P ^t4DATE MONTHIDAY/YEAR <br /> gent for N. Stockton Auto Serv. tom► 5/4/00 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 317 <br /> FFTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 / �3 i SS0 ®�C��' <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 C&OWITH THE LOCAL <br /> AGGENCY MPLEMEN,TgING THE UNDERGROUND STORAGE TAN REGULATIONS (p�� <br /> FORM A(6-95) Ive,i Ci{,� � v a" /�� � 'a�I <br /> V(J <br />