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STATE OF CALIFORNIA `^^ °p1A <br /> STATE WATER RESOURCES CONTROL BOARD } r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 'RE'NEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PER AN TL1 CL SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> Waterfront Yacht Harbor Waterfront Marina Management, Inc. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 333 Tuleberg Levee Weber <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95203 <br /> (209) 943-1848 <br /> ✓ BOX 0 CORPORATION 0 INDIVIDUAL [2§ PARTNERSHIP [] LOCAL-AGENCY CCUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> it ownerot UST is a public agency,complete the following:name of supervisor of division,section oroffice which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR FX] 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST} PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Hinrichsen Cod 209 943-1848 Van Laar. , Lammert 209 473-2001 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Hinrichsen, Cody (209) 477-3750 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COQ APLFTPM <br /> NAME CARE OF ADDRESS INFORMATION <br /> Plant "K" Partnership Delta Management Group, Inc. <br /> MAILING OR STREET ACCRESS ✓ .'-..^c!a i:.ca':* <br /> IKp'VIpUAL = LOCAL-AGENCY [] STATE-AGENCY <br /> 445 W. Weber Ave #137 0 CORPORATION XX PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#W17H AREA CODE <br /> Stockton CA 95203 (209) 464-4000 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> *See Attachment <br /> MAILING OR STREET ADDRESS ✓ box to indicate © INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TIC) HQ 4 4- -1 0 2141 <br /> 6 1 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate iAl 1 SELF-INSURED 0 2 GUARANTEE EX3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 716 EXEMPTION RD 7 STATE FUND <br /> B STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE.OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM Q 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.K] It.❑ fit. <br /> THIS FORM HAS BEEN$OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> TANK OWNIE"IS AME INTED&SIGNAT TANKOMNdE-Ill"TLEDATE MONTHfDAY/YEAR <br /> LOCAL AGENC USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -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 INFORMATION ONLY. <br /> FORM a(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />