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STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARDy. 'o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ® T PERMA T D SIT <br /> y] <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �- <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Cit of Manteca Frank Yancey <br /> ADDRESS NEAREST CROSS STREET PARCEL#IOPrIONAW <br /> 220 Oak Street Vine <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 95336 209-239-8458 <br /> BOX <br /> TOINDIIC TE CORPORATION (] INDIVIDUAL I7 PARTNERSHIP LOCAL AGENCY O COUNTY-AGENCY O STATE-AGENCY Q <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR (] ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal)RESERVATION Y <br /> Q 3 FARM 0 4 PROCESSOR ® 5 OTHER OR TRUST LANDS v <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> [NIGHTS: <br /> : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Yance Frank 209-239-8458 <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS; NAME(LAST,FIRST) <br /> Yancey, Frank 209-239-8460 PHONE#WITH AREA COE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ci <br /> MAILING OR STREET ADDRESS ✓box 0Intlhate = INDIVIDUAL LOCAL AGENCY 0 STATE-AGENCY <br /> 1001 West Center Street O CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Manteca CA 95336 209-239-8460 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Citv of Manteca <br /> MAILING OR STREET ADDRESS ✓box to indicate 0 INDIVIDUAL E7:1 LOCAL-AGENCY 0 STATE-AGENCY <br /> 1001 West Center Street O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Manteca CA 95336 209-239-8460 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41-4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box In hftale 1 SELF-INSURED E-1 2 GUARANTEE 3 INSURANCE 4 SURETY BONG <br /> D 5 LETTEROFCREOIT 0 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.® III.❑ <br /> THIS FORM HAS BEEN COMP UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRIN41Q&SIGINATUR APPLICANTS TITLE DATE MONTH/OAYNEAR <br /> Jim Podesta De . Director Pub. Works (o Z <br /> LOCAL AGENCY SE NLY <br /> UN # JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 111 VI/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• <br /> FORM A(5-91) FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR0033A5 <br />