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3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 'e,�'• e I / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA la COMPLETE THIS FORM FOR EACH FACILITYISITEFn� 3 `'•.o••' MARK ONLY pl"I1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) E±A91q 'g q0 ' NAME OF OPERATOR DBA OR FACILITY NAME L.R. Varwig Property L.R. Varwi ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 16500 E. Brandt Rd. Jack To CITY NAME STATE LP CODE SITE PHONE#WITH AREA CODE Lodi, CA 95240 N/A ✓BOX O CORPORATION El INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS low oUSTbepubkapenq,wmpMeIMblbwn¢nameofa orMordcrwim,sedbnwalrmwhkhopowm Lire UST TYPE OF BUSINESS E:] I GAS STATION E::] 2 DISTRIBUTOR ^ ❑ RESERVATION X OF TANKS AT SITE E.P.A. I.D.N(optional) ❑ 3 FARM ❑ 4 PROCESSOR a] 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE Varwig, - NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,RBST) PHONE p WITH AREA CODE Same as above If. PROPERTY OWNER INFORMATION-(MUSTBECOMPLFTFD) NAME CARE OF ADDRESS INFORMATION L. Roger Varwig MAILING OR STREET ADORE INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY P.O. box 99320 O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE X WITH AREA CODE Stockton, CA 95209 - III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER L.R. Varwig, CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ b"tohcrale INDIVIDUAL LOCAL-AGENCY DSTATE-AGENCY P.O. Box 99320 ED CORPORATION ED PARTNERSHIP 0 COUNTY-AGENCY ED FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Stockton, CA - 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 ✓box to iMmle I SELF-INSURED ED 2 GUARANTEE ll 3 INSURANCE O 4 SURETY BOND ED 5 LETTEROFCREDIT D 6 EXEmpnoN O T STATE FUND R B STATE FUND&CHIEF FINANCIAL OFFICER LETTER [719 STATE FUND&CERTIFICATE OF DEPOSIT 016 LOCAL GOVT.MECHANISM ED 99 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: L❑ II.® III.❑ n1 AS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT (PRINTED 851GNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR 'Z4 1446'0-'V� I PAE's 4&—VnR I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# ^ FACILITY# EE LOCATION CODE -OPTIONAL CENSUS TRACT;—OPTIONAL-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 FORM A(6-95)