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• STATE OF CALIFORNIA ...... <br /> ^e�."'•.e <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A tlI lie <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT LSED" E <br /> ONE ITEM 2 INTERIM PERMIT Q d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> &l <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS Lodi Dodge Chrysler Plymouth W611 Lodi Dodge Chrysler Plymouth (, <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2 W. Lockeford St. Sacramento St. <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 1 209)369-2739 <br /> ✓ BOX CORPORATION (] INDIVIDUAL [)0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY' <br /> TO INDICATE DISTRICTS 0 FEDERAL-AGENCY' <br /> #ownerd UST b a public agency.mmpMte the following,name d sgeMearol dMion,section or office which#pemtes the UST <br /> TYPE OF BUSINESS a t GAS STATION O 2 DISTRIBUTOR V, ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O O Ly 5 OTHER 0 RESERVATION 1 CAC 001435960 <br /> 3 FARM 6 PROCESSOR OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> Rick Guajardo (209)369-2739 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Tr' <br /> Ist <br /> MAILING OR STREET ASES ✓ bcx to nd�'o 1EVINDNIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 1408 Rosario St. 0 CORPORATION O PARTNERSHIP O COUNTY--�AApGEN7CjY}��EgQ�{FEDERAL-AGENCY <br /> CITY NAf5a VIS STA16A ZI�`.gD 16 PJ3U�1/Jb-4L 1� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Weil Family Trust Roberta Allen <br /> MAILING OR STREET ADDRESS ✓ boxtondLate INDIVIDUAL =LOCAL-AGENCY O STATE-AGENCY <br /> 1408 Rosario .Cit. l=CORPORATION O PARTNERSHIP = COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITHAREA CODE <br /> Davis, CA 95616 (530 756-4216 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1SELF-INSURED = 2 GUARANTEE = 3 INSURANCE O d SURETY BOND (] S LETTER OF CREDR O 8 EXEMPTION Q 7 STATE FUND <br /> &STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 1= 10 LOCAL GOVT.MECHANISM 099 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I of II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EJ II.® III.O <br /> TH/ R S BEE M ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK NA RI T 1 Family Trus TANK OWNER'S TITLE DATE MONTH/DAV/YEAR <br /> b ichar Thorpe, Contractor Owner 2/17/00 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY It t <br /> m � l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ,may <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK RE9PLATIONS �^Jv(� <br /> FORMA(6-95) ,X <br />