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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD iy <br /> `,yjpERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY LHill •E RMIT 7 RENEWAL PERMITS 5 CHANGE. OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT L.,_I 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS• (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> PIEDMONT LUMBER & MILL CO., INC_, UNKNOWN <br /> A/777 WEST ELEVENTH STREET � ssrREBT PARCEIa(OPgNAy <br /> CITY NAME STATE ZIP CODE SITE P ON a WITH AREA CODE <br /> TRACY CA 95376 510 674 8770 <br /> TO INDICATE CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS r-1 I GAS STATION ( _',, 2 DISTRIBUTOR -'- ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.a(optional)RESERVATION <br /> r" S FARM -I 4 PROCESSOR I1] 5 OTHER OR TRUST LANDS ONE CAC000760344 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) $32 8400 <br /> EDWARD P. SMITH 10 6 4 8 0 DOUG MARSTALL (209) COOL. _ _ <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SAME SAME WITH ARPA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> PIEDMONT LUMBER & MILL CO. INC. MR. EDWARD P. SMITH CFO <br /> MAILING OR STREET ADDRESS ✓ box ID WN a [:1 INDIVIDUAL 0 LDCAL•AGENCY ED STATEAGENCY <br /> 395 TAYLOR BLVD. SUITE 225 CORPORATION O PARTNERSHIP 0 COUATY#GEWY [:) FEDERAL-AGENCY <br /> �� ANT HILL SIA,TE ZIP CODE PHONE a WITH AREA CODE <br /> l.H 94523 (510) 674 8770 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF A OR SS INFO <br /> PIEDMONT LUMBER & MILL CO., INC. MR.EDWDARR7 PN %AM, CFO <br /> MAILING OR STREET ADDRESS ✓ WA bIn kau [::I INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 395 TAYLOR BLVD, SUITE 225 Cn CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY E:I FEDERAL.AGENCY <br /> CITY NAME STATE ZIP CODE PNE WITH E <br /> P CA 94523 (5HOa10) 674 AREA 877COD0 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)323.9555 if questions arise. <br /> TY (TK) HO 'I.4-1 4 _L_� i -_ L- _I NA <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY• (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Ib�blMkata I_..] I SELF INSURED ] 2 GUARANTEE —L:] S INSURANCE n 4 SURETY BOND <br /> 5 LETTEROFCREOT .i 6 EXEMPTION L�(9a OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal noofcalion and billing will be sem to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE AOORFSS SHOULD BE USED FOR LEGA: NOTIFICATIONS AND BILLING l F] II.[X-1 111.❑ <br /> THIS FOR S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPIICA N NTEDB SIGNATURE( APPLICANT'S TITLE DATE ONTWDAY/YEAq <br /> OCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY#eo'�2 99 <br /> FT-1 3 yE <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT a .OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FOXaa73A 5 <br />