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00S. <br /> STATE OF CALIFORNIA 0STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lyl 5 CHANGE OF INFORMATION ® 7 PERMAN SED SITE <br /> ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT Y❑ a TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Warren Shann <br /> ADORE Waste Water Quality Control Faci Nf-�,98T CROSS STREET PARCELp(OPfK1NAM <br /> 2,1511 Yosemite Ave cz,'f <br /> CITY NAME STATED' ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 95336 909-239-8433 <br /> 11 x <br /> TOINDIC TE =CORPORATION INDIVIDUAL =PARTNERSHIP E& LOCAL-AGENCY COUNTY AGENCY I= STATE.AGENCY = FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR I= ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER ORT RUSESET LANDS 1 <br /> ❑ ❑ AL000095996 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Jessep. nang 209-239-8433 PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Jessee , Dane 209-239-8433 PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Citv of Manteca Marcia Cwick <br /> MAILING OR STREET ADDRESS ✓ bmbiMicale = INDIVIDUAL lX LOCAL-AGENCY = STATE AGENCY <br /> 1001 W . Center St . =CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Manteca CA 95336 209-239-8465 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> City of Manteca Marcia Cwick <br /> MAILING OR STREET ADDRESS ✓ box 0Inbbate = INDIVIDUAL [)0 LOCAL.AGENCY = STATE-AGENCY <br /> 1001 W . Center S t . =CORPORATION = PARTNERSHIP =COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Manteca CA 1 95336 209-239-8465 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 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 bixMIcale I SELF-INSURED =2 GUARANTEE = 3 INSURANCE =d SURETY BOND <br /> =5 LETrER OF CREDIT =6 EXEMPTION = 9 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.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETE UNDER PENALTY ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTEDB NATUR APPLICANTS TITLE DATE MONTHIDAWYEAR <br /> Keith A . Talli4�m A ent 3/15/9 <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION It �FACIL�ITY# <br /> ® 9"] <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I jam, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A5 <br />