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\ STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /�-.-5-7 7 DBA OR FACILITY NAME NAME OF OPERATOR The Stockton Record Stockton Newspapers, Inc. ADDRESS NEAREST CROSS STREE Q / PARCEL#(OPTIONAL) 530 E. Market St . .49MIT-4aattn tt+ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Stockton, CA 95202 (209)943-8550 ✓ BOX ®CORPORATION 0 INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency.complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS a 1 GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR ® 5 OTHER OR TRUST LANDS 1 CAC 002559617 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Frankel Jim (209)94 -8550 NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Frankel , Jim 943-8550 II. PROPERTY OWNER INFORMATION-(MUST 13E 0Ofl#PLFTFD) NAME CARE OF ADDRESS INFORMATION Stockton Newspapers, Inc. MAILING OR STREET ADDRESS ✓ bcx to r:ra a O INCIVIDUAL LOCAL-AGENCY STATE-AGENCY P.O. BOX 900 W CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE StQ(-.ktnn CA CA 95201 r III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Stockton Newspapers, Inc. MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Stockton, CA 95201 (209)943-8550 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 to indicate 0 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE O 4 SURETY BONO = 5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND 6 STATE FUND d CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 99 OTHER 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 FOR LEGAL NOTIFICATIONS AND BILLING: I.a 11.® III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNAT ) TA OWN 'S TITLE DATE MONTHiDAYNEAR V 71— 4 LOCAL AGENCY US9 ONLY COUNTY# JURISDICTION# FACILITY If FT-1 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)