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• • t60U. � C STATE OF CAUFORTHA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ T NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION © 7 PERMANENTLY CLOSED SIT ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE 5 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Marlene Sahla Parcel Trimark Communities ADDRESS NEAREST CROSS STREET PARCEL#(OPTUM 18621 Mountain House Parkway B ronRoad CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Tracy CA 95376 ✓ BOX TOINDICATE CORPORATION Q INDIVIDUAL PNITNFILSHIP Q LOCCY 0 COUNTY-AGENCY' O STATE-AGENCY' (]FEDERAL-AGENCY' DISTRICTS'RICTS'flICTS' •N oener of UST Is a public agency,complete the following:name of Supervisor W tlNbbn,secl'an,or office vAtbh aperatec the UST TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR = RESERVATION IF INDIAN AOF TANKS AT SITE E.P.A. I.D.0(colonel) 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE A WITH AREA CODE Gross, Ron 209 835-1560 NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION Trimark Communities MAILING OR STREET ADDRESS ✓Ou loineale F-) INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 3120 Tracy Blvd. ®CORPORATION = PARTNERSHIP = COUNTYAGENCY = FEDERAL-AGENCY CITY NAME STATE21P CODE PHONE A WITH AREA CODE Tracy CA 95376 (209) 836-1560 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Trimark Communities MAILING OR STREET ADDRESS ✓ boxbinEbaN = INDIVIDUAL O LOCAL-AGENCY E-1 STATE AGENCY 3120 Tracy Blvd. X1 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE Tracy CA 95376 (209) 836-1560 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box bindbzle O 1 saFtwuRED O 2 GUARANTEE EN 3 INSURANCE A SURETY BOND O 5 LEREROFCREDIT O It ExEIAPTION O MOTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOP LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTEDB SIGNED) OWNER'STIrLE GATE M T Y/YFAfl LOCAL AGENCY USE ONLY COUNTY JURISDICTION If FACILITY# 6) LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL h7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INIFOWATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) • 1-0R0333AA] Ilk •