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iN„ C �l C STATE OF CALIFORNIA :� no STATE WATER RESOURCES CONTROL BOARD ..,� - :6 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY E:1 t NEW PERMIT 3 RENEWAL PERMIT F71 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE _ ONE ITEM LI-1 2 INTERIM PERMIT [:j A AMENDED PERMIT E] S TEMPORARY SITE CLOSURE D I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Pacific Bell ADDRESS NEARESTCROSS STREET PARCEL 0(OPTIONMI 1413 Bourbon Street CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE Stockton CA 95204 I/ Box TO INDICATE 1I CORPORATION D INDIVIDUAL O PARTNERSHIP [:13 LOICALAGENCY ED COUNTY-AGENCY' Q STATE-AGENCY' O FEDEML-AOENCY' If owner d UST is a public agency,comlele the following:natro of SupervNar 01 dNiebn,sedion.W of ic,which operates the UST TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR RESERVATION a TANKS AT SITE E.P.A. I.O.i(nWAmal) 3 FARM [_�] 0 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Pacffic Bell Emer encu Control (510)1823-7777 _ NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NX3HTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED NAME CARE OFACORESS INFORMATION L�a,��q Pacific Bell — PCirmc Uc� E�a1 d?a�La L�r.b MAILING OR STREET ADDRESS ��p .1bot bin&n [__1 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCYo n r 1 1 CORPORATION O PARTNERSHIP =COUNTY-AGENCY O FEDERAL AGENCY ICIQ Isinxie" s.. SIC,,. STATE ZIP CODE PHONE a WITH AREA CODE Sei3 amQn SGS: c ' ,c .+� S AcI III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CIUO NA�OFOW R CARE OF ADDRESS INFORMATION C \ Lo cZ MAILMO OR STREET ADDRESS ✓OoybkANW 0 INDIVIDUAL tic CAL-AGENCY Q STATE-AGENCY 24CORPORATION D PARTNERSHIP O COUNTYAGENCY D FEDEML-AGENCY CITY NAME STATE I IF CODEPHONE a WITH AREA CODE 17408 -, uh g3--loL CzcDa - Ltz_- 2288 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY Ti HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bhbbaM 0 I SELF-INSURED 2 GUARANTEE [:j 3 INSURANCE O I SURETY BOND 5 LETTER OF CREDIT O 6 EXEMPTION O MOTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sem 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: 1.O II.$ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF AIY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAY1YEAR LOCAL AGENCY USE ONLY �_J;d Tb COUNTY N JURISDICTION a FACILITY It LE 1 13 q LOCATION CODE -OPTIONAL CENSUSTRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o8ESy THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) v �\' 1 � �� I � FOHIQTUAT