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• r L <br /> f ♦ STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i rte, e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e, e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE iB <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) ' <br /> DBA OR FACILITYNAME NAME OF OPERATOR <br /> Eastand Plaza Henery Barkett <br /> ADD NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> 8 North Wilson Way Oak street <br /> CITY NAME STATE ZIP CODE SITE PHONE I WITH AREA CODE <br /> Stockton CA 95 1 209 951 -57- <br /> ✓ BOX Q�XORPORAnm ❑ INDIVIDUAL C3 PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> Io. er of UST a a public agenq,ro plele roe fotov g:rams of sWenuord crMsan,swan or Or"Ad aperzles the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION O 2 DISTRIBUTORO ✓IF INDIAN I OF TANKS AT SITE E.P.A. 1.D.I(optional) <br /> ❑ <br /> 3 FARM a PROCESSOR 5 OTHER RESERVATION❑ OR TRUST LANDS one <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> Hpnprm RnZ­kpf-i- 209 951 -S787 Sams <br /> NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Eastland Plaza <br /> MAILING OR STREET ADORE SS ✓ W.Wedule DyDMDUAL C—]LOCAL-AGENCY EDSTATE-AGENCY <br /> Box 4146 Sto,­kt n CA O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAM $TATE 21P CODE PHONE I WITH AREA CODE <br /> CA 95204 209 951 -5787 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo.Io ntlaab QpIpRADUAL ❑LOCAPAGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAFE STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓W.IY id"I. I= i SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE Q/ SURETY BOND 5 LETTEROFCREDn Q 6 EXEMPTION O T STAT FFUND <br /> 08 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND 6 CERTIFICATE OF d0ftIT Q Ip LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TOWNER'S TITLE DATE MONTWDAWVEAR <br /> r �c� ANK1^ aL <br /> LOCA AGENCY USE ONLY IF <br /> COUNTY N JURISDICTION$ FACILITY p <br /> m Em 1 11 <br /> LOCATIONCOOE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEr�t)OR MORE PERMIT APPLICATION- FORM B,UNLESS�S A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6.95) <br /> OWNER MUST FILE THIS FORM HE LOCAL AGENCY IMPLEMENTING THE UNDERGROU ORAGE TANK REGULATIONS <br /> Ub 8`l°sD/0 <br />