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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATI0 P R C4gSEE SITE ONE ITEM O 2 INTERIM PERMIT Q d AMENDED PERMIT O 6 TEMPORARY SITE CLO URE / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ; DBA OR FACILITY NAME NAME OF OPERATOR Gateway Project City of Stockton JJL17E-UC-LCv?m&t -t �T(-tlicLI 41 ADDRESS $ OC OliLl ed y t.afayette, I NEAREST GROSS STIR <7 , k El DOr� . onora 7,; �rM tYL 14 M —G CITY NAME STATE ZIP 96DE SITE PHONE N WITH AREA CODE Stockton CA ✓ BOX ]CORPORATION ] INDIVIDUAL E3 PARTNERSHIP il]LOCAL-AGENCY COUNTY-AGENCY' ] STATE-AGENCY' (] FEDERAL-AGENCY' TO INDICATE DISTRICTS 'N oawrol USTls a Public agenry.mnpiete the lolbwhg:name of werviso of division,wtion orokce whir operates the U `-r. Bon Palmquist TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN N OF TANKS AT SITE E.P.0. I.D.N/optional) O O = RESERVATION Unknown 3 FARM 0 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Crawford, Jo}Ln (HBI) 925-443-0225 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE N WITH AREA CODE Crawford, .john (EBI) 925-395-8200 II. PROPERTY OWNER INFORMATION-(MUST BE CODAPLFTFn) NAME C�A@FE OF ADDRESS INF A.AltL ` Mr. Ron Palmquist + LOU51N� ;�r�U�WQMF1tk MAILING OR STREET ADDRESS ` ✓ =c"oi'=�'- I✓, N9:VIDUAL � LOCAL-AGENCY I� STATE-AGENCY 305 1'. El Dorado Street - �` L ITE -Cj ]CORPORATION ] PARTNERSHIP ] COUNWAGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONE N WITH AREA CODE Stockton CA 195202 209-937-8538 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER C�qRE OF ADDRESS INFORM �'[ at. Ron Pilmquist YmCFrjIN(� 4� i[.0 t� U�r"--t-(��r MAILING OR STREET ADDRESS _22v ,l ✓ bon toidiate INONIDUAL �LOCAL-AGENCY O STATE-AGENCY 305 N. El Dorado Street — JLL.L,�( 4 " C V ]CORPORATION ] PARTNERSHIP ] COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE Stockton CA 95202 209-937-8538 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓be,NilQAata C:nl SELF-INSURED I] 2 GUARANTEE O 3 INSURANCE ]a SURETY BOND I] 5 LETTER OF CREDIT I]a EXEMPTION ]7 STATE FUND ] &STATE FUND&CHIEF FINANCIALOFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT ] 10 LOCAL GOVT.MECHANISM O99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11.A III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWN RS NAME(PRINTED&SIGNA TANKOWNER'S TLE V — vs N(q DATE MONTWDAY/YEAR �t�L�,i L��J 51 24c — C.F7, LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N p FACILITY N m I S 15 LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LCAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR. I THE LOCAL AGENCY IMPLEMENTING THE UNDERGR( -t uRAGE TANK REGULATIONS FORM A(6.95)