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STATE OF CALIFORNIA �✓ e�sow+ e o <br /> STATE WATER RESOURCES CONTROL BOARD 'g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� ae <br /> C.t�.O+M. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATIONEAMANEE/NTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE , r <br /> 0023" 1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Tri Star Homes LLC Stephen Bailey <br /> 1329 N. CorralADDRESS NEAREST CROSS STREET PARCEL*(OPTIONAL) <br /> Rd. <br /> Byron HW <br /> CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tracy, CA 9 q N/A <br /> TOININCATE O CORPORATION 0 INDIVIDUAL EX PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY 771 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.I Jgptimal) <br /> RESERVATNJN <br /> 0 3 FARM 0 4 PROCESSOR X] 5 OTHER OR TRUST LANDS 2 CAC 001166584 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: AME( AS FIR T) (209)839—HgNE WITH AREA CODE DAYS:Bal eST,FI ST) <br /> 1 p , y f y, tephen (510)838-1460 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Same as above Same as above PHONF*ZEIIH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Tri Star Homes LLC <br /> MAILING OR STREET ADDRESS ✓box blydbW INDIVIDUAL O LOCAL-AGENCY D STATEEAGENCY <br /> P.O. BOX 1056 O CORPORATION PARTNERSHIP O COUN Y-AGENCY D FEDERAL-AGErY <br /> CITY NAME STATE ZIP CODE PH ONE WITHAREACODE <br /> Alamo CA 94507 CA 94507 (510)838-1460 <br /> Ill. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ CorbiMkaro ,mac, INDIVIDUAL O ENCY LOCAL-AGENCY STATE-AG <br /> P.O. Box 1056 0 K <br /> CORPORATION PARTNERSHIP E�]COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Alamo CA 4 0 510)838-1460 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4_ 4L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicale 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BONG <br /> D 5 LETTEROFCREDIT 0 6 EXEMPTION 0 W 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: 1.0 11.I : III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALT OF PE�WVRY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> If 1.4 <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) is ar O e PLICANPSTITLE DATE MONTWDAYNEAR <br /> Agent for Tri Star Homes,LLC Owner 5/21/97 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 1pl <br /> — -- — -- <br /> LOCATIONCODEOPTIONAL iCENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> OIL, 1-6411 <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 />`RM A(1291) FILE THIS FORM WITH THFLOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> N `/ FOR6033AP6 <br />