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COUNTY # JURISDICTION# FACILITY # 3 [f) CENSUS TRACT 8 - OPTIONAL SUPVISOR - DISTRICT CODE - OP770N4L v_6—qc( LOCATION CODE • OPTIONAL I 2Y-0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILRWSITE MARK ONLY I I 1 NEW PERMIT I I 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I [ 7 PERMANENTLY CLOSED,EffT-E--,, ONE ITEM [ 2 INTERIM PERMIT I 4 AMENDED PERMIT I 6 TEMPORARY SITE CLOSURE ( I. FACILITY/SITE INFORMATION & ADDRESS • (MUST BE COMPLETED) --BEM OR FACILITY NAME iver City Petroleum Commercial Cardlork NAME OF OPERATOR River City Pptrn1Pum ADDRESS 2211 N. Wilson Way NEAREST CROSS S REET Bradford PARCEL a (OFTFONAL) CITY NAME Stockton STATE CA ZIP CODE 9 U_O 5 SITE PHONE a WITH AREA CODE ( 2 0 9 ) 948-'1434 TO INDICATE LT6t CORPORATION n INDIVIDUAL I___1 PARTNERSHIP n LOCAL-AGENCY n COUNTY-AGENCY ' l__I STATE-AGENCY' = FEDERAL-AGENCY ' DISTRICTS' If owner of UST is a public agency. complete the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS t1(7c 1 GAS STATION I _ I 2 DISTRIBUTOR I I 3 FARM I I 4 PROCESSOR 1 I 5 OTHER I I REVSEIFIF yINATDIIOANN OR TRUST LANDS a OF TANKS AT SITE 3 E. P. A. I. D. a (opt ional) EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE Pager Answering Machine (916) 371-4960 DAYS: NAME (LAST, FIRST) Heckman Sheldon PHONE a WITH AREA CODE (209) 948-3434 NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE Pager Answering Machine (916) 371-4960 NIGHTS: NAME (LAST, FIRST) Heckman, Sheldon PHONE a WITH AREA CODE (209) 952-1675 PROPERTY OWNER INFORMATION - MUST BE COMPLETED NAME Connell Motor Truck Co., Inc. CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS P. 0. Box 8467 ../ box 0 indicate I I INDIVIDUAL n LOCAL-AGENCY T-7 STATE-AGENCY [g] CORPORATION I I PARTNERSHIP 711 COUNTY-AGENCY 1 j FEDERAL-AGENCY CITY NAME Stockton STATE Ca. ZIP CODE 1 PHONE a WITH AREA CODE 95208 1(209) 948-3434 TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER Connell Motor Truck Co., Inc. CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS P. 0. Box 8467 sr' box to indicate t I INDIVIDUAL n LOCAL-AGENCY n STATE-AGENCY xx CORPORATION ET PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME Stockton STATE Ca. ZIP CODE 95208 PHONE a WITH AREA CODE (209) 948-3434 BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER • Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4- PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED box b indicate I I 1 SELF-INSURED I 2 GUARANTEE 3 INSURANCE I I 4 SURETY BOND = 5 LETTER OF CRECXT El 6 EXEMPTION 99 OTHER State Fund LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ll is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 1 II. III.' 1 XX THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED 8 SIGNED) Connell Motor Truck Co., ,Icipi_.4f: lw . ShPlrinn Hprkman ...1_1. OWNER'S TITLE Prpcirtont DATE MONTH/DAY/YEAR Vinicia OCAL AGENCY USE ONLY THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPUCATION • FORM B, UNLESS THIS IS A CHANGE OF SITE INFORIAATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEPENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (3/931 FOR0033A-R7