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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w� � <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> TSI Trans System Inc . _ GF_© v <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 707 Rath Rd . Valleio Court <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> Lathrop CA95296 Pnq <br /> . 82 <br /> I/ BOX �c — — <br /> TO INDICATE L0281 <br /> J CORPORATION ®INDIVIDUAL = PARTNERSHIP ®LOCAL-AGENCY I] COUNTY-AGENCY [] STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORRESERVATION IF INDIAN #OF TANKS AT SITE E.P.A. f1I.f1D..4s(oplional) <br /> 3 FARM 4 PROCESSOR �n i 5 OTHER 08 TRUST LANDS '1, �,A L 0 0 015 6 7 7 6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> Oliver , Rex 209-982-0281 PHONE g W17H ARE CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> TSI Trans System Inc . <br /> MAILING OR STREET ADDRESS ✓ box to indicate F7 INDIVIDUAL ED LOCAL-AGENCY 0 STATE-AGENCY <br /> P . O . Box 3456 LX CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Spokane WA 99220 509-623-4gOO <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> TSI- Tran System <br /> MAILING OR STREET ADD RESS ✓ box 0 indicate 0 INDIVIDUAL 0 LOCAL-AGENCY L] STATE-AGENCY <br /> P . O . Box 3456 CORPORATION = PARTNERSHIP LD COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE;('WITH AREA CODE <br /> —Spokane WA 99220 509-623-4000 <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> F4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 10 Indicate = 1 SELF-INSURED [—]2 GUARANTEE ] 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 716 EXEMPTION [] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner u less box I or II is Checked. <br /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED 1! ER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGN URE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> Keith A . 7allia Agent 6/ 1/95 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# � / 7a <br /> m s a 73 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT 8 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFOINATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />