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STATE OF CALIFORNIA /903 STATE WATER RESOURCES CONTROL BOARD c��+ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT E:D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIOND ONE ITEM E::] 2 INTERIM PERMIT O T PERMANENTLY CLOSED SITE Q 4 AMENDED PERMIT � e TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) F-# e0/f W DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS The City of Stockton NEAREST CROSS STREET PAgCELtl(OPTIONALI 428 E. Fremont St . Sutter St . @gggggggggg CITY NAME STATE ZIP CODE Stockton, CA CA 95202,BoxST SITE PHONERWTH AREA CODE TOTE 0 CORPORATION E=1 INDIVIDUAL O PARTNERSHIP L`J LOCAL-AGENCY Q COUNTY-AGENCY' Q STATEAGENCV' Q FEDERAL-AGENCY' 'I omwd USTs. DISTRICTS PIAa�eWao/.NnNslealebaoatig.name d slgeabord ONsion,sedan aalfiw eM1iM opaiates the UST SpTYPEOFBUSINESS O 1GASSTATION O 2DISTRIBUTOR FINDIAOFTANKSATFE oal)RESSVATION 1 8 0Q 3 FARM Q 4 PROCESSOR ® 5 OTHER ORTRUTLANDS 1 CAC 0025684 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE Wahl 0 Rd (209)937-9258 NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE Same as above II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFDI NAME CARE OF ADDRESS INFORMATION The City of Stockton MAILING OR STREET ADDRESS ✓ 0cs to rl a 0 INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY 445 N. E1 Dorado St. O CORPORATION 0 PARTNERSHIP Q COUNTY.AGENCY O FEDERAL-AGENCY CITY NAME STATE 21P CODE PHONE I WITH AREA CODE 937 Rtopktnn 95 (209) III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION The City of Stockton MAILING OR STREET ADDRESS ✓ Emloin61ale [:1 INDIVIDUAL [g LOCAL-AGENCY INSTATE-AGENCY 445 N. E1 Dorado St. O CORPORATION = PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE R WITH AREA CODE Stockton, CA 95202-1997 (200) 937-8358 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Ooxb il�aU ] 1 SELF-INSURED O 2 GUARANTEE =3 INSURANCE M 4 SURETY BOND =5 LETTEROFCREDR I=6 EXEMPTION O T STATE FUND OaSTATE FUND 6CHIEF FINANCIAL OFFICER LETTER =aSTATE FUND BCERTIFICATE OFDEPOSIT O10LOCALGOVT.MECHANISM O NOTHER 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 II.® III.O THISF MHA EN COMPLETED UNDER PENALTY PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK O AME( I ED SIGNA RE) TAN E TITLE DATE MONTWDAV/YEAR -O LOCAL AGENCI USE ONLY COUNTY R JURISDICTION X FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 0.UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6.95)