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STATE OF CALIFORNIA WATER RESOURCES CONTROL BElf <br /> � 7 <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMFEB 1 6 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT kW10IlBWlWi4AL I <br /> /7 COMPLETE THIS FORM FOR EACH FACILITY/SITE PERMI /SERVIC y <br /> MARK ONLY Q I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE 7..1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) W <br /> t0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION {A <br /> Stockton Metropolitan Transit District 1533 East Lindsay Street <br /> ADDRESS NEAREST CROSS STREET ✓E000ir4ale D PARTNERSHIP D STATE AGENCY <br /> Fremont D OOPORXTON �1 LOCAL AGENCY D FEGERALAGDRY <br /> 1533 East Lindsay Street ❑ iNDPIOLN. D COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Stockton CA 95205 CA 95205 (209) 948-5566 <br /> I EPA ID M <br /> TYPE OF BUSINESS: ❑ 2 pISTHIBUiOR ❑4 PROCESSOR Sox N INDIAN _ EDI TANK', <br /> RESERVATION or AT THIS SITE 10 <br /> ❑1(i4S5TATI0N ❑3 FARM ®5 OTHER TRUST LANDS ❑ CAD981675093 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> Jones Elliott (209)948-5566 Brown, Peter (209) 948-5566 <br /> NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Jones Elliott (209)473-8732 Brown, Peter (209) 478-5936 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stockton Metropolitan Transit District 1533 East Lindsay Street <br /> MAILING or STREET ADDRESS -/Box to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION $1 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 1533 East Lindsay Street D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Stockton CA 95205 (209) 948-5566 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stockton Metropolitan Transit District 1533 East Lindsay Street <br /> MAILING or STREET ADDRESS ✓Box toindicalePARTNERSHIP D STATE-AGENCY <br /> D CORPORATION � LOCAL-AGENCY D FEDERAL-AGENCY <br /> 1533 East Lindsay Street D INDIVIDUAL D COUNTY-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Stockton CA 95205 (209) 948-5566 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ® 11. ❑ Ill.❑ <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&SIGNATURE) DATE <br /> Elliott C. Jones <br /> LOCAL AGENCY USE ONLY <br /> �UNTYY� JURISDICTION E AGENCY.% FACILITY ID M Al of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE If WITH AREA CODE <br /> 7 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE T E CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> V/ <br /> ')3. 5 2 '2 YES NO <br /> CHECK N L/ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIM k BY: <br /> 3 <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION OY <br /> FORM/`(3-2-SS) <br /> DATA PROCESSING COPY 'OV, <br />