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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STf3RAGE TANK PERMIT APPLICATION - FORM A <br /> ;4, <br /> COMPLETETHIS FORM FOR EACH FACILITYISITIE <br /> MARK{}N Y 1 W PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CL 1� / <br /> ONE ITE INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE }11 <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OMNAIAE <br /> NABS A OPERATOR <br /> ORCLY HARDWARE DISTRIBUTION CEN E PARC EL0(OPT)ONAQ <br /> ACORNEAREST CROSS STREET <br /> 265AC ARTHUR DRIVE GRANT LINE <br /> CITY NSTATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> TRACA 45376 204-833-3100 <br /> TCORPORATION 0 INDIVIDUAL Q PARTNERSHIP 0 LOCAL•AGENCY � COUNTY-AGENCY [] STATE-AGENCY � FEDERAL-AGENCY <br /> bISTRICTS <br /> IF INDIAN o OF TANKS AT SITE E.P.A. I.D.A(oplianalJTYPE1 GAS STATION 2 DISTRIBUTOR RESERVATION 3 FARM 4 PROCESSOR tl 5 OTHER OR TRUST JV <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) optional <br /> [DAYS: FIRST) PHONE X WITH AREA CODE DAYS: NAME{LAST,FIRST}IZ 204-833-31100 TIM ESPANSANDIN 408— —2fZFIRST) 209-524Pi E6x2WITHAREACODE �I�s'ESPA�TSTANDI�T 510-732-0638 <br /> w H AREA CODE <br /> II.' PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAVE <br /> ORCHARD SUPPLY HARDWARE TIM ESPANSANDIN <br /> NAILING ORSTREET ADDRESS P �� �')( L� f}!� V box qIndicate Q INDIVIDUAL Q LOCAL-AGENCY � STATE-AGENCY <br /> !! ]CORPORATION PARTNERSHIP COUNTY.AGENCY [] FEDERAL AGENCY <br /> CITY NAME STAT ZI D PHOJI��Arf <br /> SAN JOSE, CA 9 GSA 1 a2 [}} <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> TIM ESPANSANDIN <br /> ORCHARD SUPPLY HARDWARE <br /> MAILING OR STREET ADDRESS ODE <br /> rJ�i box ID'W'ca« � INDIVIDUAL � LOCAL-AGENCY 0 STATi:-AGENCY <br /> 6450 VIA DEL ORO i N CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIPODEPytD[J p19 AR)<�a0 <br /> SAN JOSE lL}}uu L 1 j [j <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 -10 3432 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED 2 GUARANTEE 0 7 INSURANCE 0 4 SURETY BOND <br /> J poxmiMcale C� a EXEMPTION 99 OTHER 5 LETTER OF CREDIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or li is checked. <br /> FCHECK ONE SOX INDICATING WHICH ABOVE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. IR. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY'OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&St TUBE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> HARRY FISHER Wv <br /> CONSTRUCTION MANAGER 5/13/42 <br /> LOCAL AGENCY USE 00 Y _ 5,-1;_9 <br /> COUNTY 9 JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DIST ICT CODE •OPTIONAL <br /> 7:1 <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.FORM3s <br /> FORM A(5.91} <br />