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Owl <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s� - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 'o=rs <br /> N > . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ® I NEW PERMIT 3 RENEWAL PERMIT _ 5 CHANGE OF INFORMATION [::1 ERM`AINENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> Tri Star Homes LLC Stephen Bailey _ <br /> ADDRESS NEAREST CROSS STREET PAflCELp (OP(IONAL) <br /> 1N Corral ow Rd Ryro <br /> CITY NAME STATE I ZIP CODE . per SITE PHONE WITH AREA CODE <br /> Tracy , CA 9 1 N/A <br /> BOX TOINDICATE I� CORPORATION INDIVIDUAL PARTNERSHIP D LOCAL NCV 1 COUNTY-AGENCY I� STATE-AGENCY l� FEDERAL-AGENCY <br /> DISTRICTS <br /> IF INDIAN <br /> TYPE OF BUSINESS O ) GAS STATION 2 DISTRIBUTOR I-- RESERVATION A OF TANKS AT SITE E. P. A. I. D. N (optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER GR TRUST LANDS 2 CAC 001166584 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br /> DAYS: AME (LAST, FIR T) NE M WITH AREA ODE DAYS: NAME (LAST, FIRST) <br /> �horpe , Felly ( 209 2�95 ,� Bailey , Stephen <br /> ��a� _ - PUONEJLWQ}iAREA.CODE__ <br /> NIGHTS: NAME (1-MT, FIRST). PHONE M WITH AREA CODE NIGHTS: NAME (LAST, FIRST) <br /> Same as above Same as aboveEHQNF # WITH AREA CODE <br /> Q `\ 11 . PROPERTY OWNER INFORMATION • MUST BE COMPLETED <br /> NAME - � ' ARE OF ADDRESS INFORMATION <br /> _Tri Star Homes , LLC - - <br /> MAILINGORETREETADDRESS x, biMkale INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> P . O . BOX 1056 Da I? I CORPORATION EM PARTNERSHIP 0 COUNTY AGENCY I l FEDERAL AGENCY <br /> CITY NAME5 ATE ZIP CODE PHONE N WITH AREA CODE <br /> Alamo , CA 94507 Oa CA 94507 -159 }838-1460 - . <br /> CL It <br /> III. TANK OWNER INFORMATION - ST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION - <br /> �rSar Homey-T T ( V bi�dcala <br /> ' MAILING ORF STREET ADDRESS I x, L:::] INDIVIDUAL EDLCGAL-AGENCY E::] STATE-AGENCY <br /> P . O . BOX 1056 C COflPORATION IX PARTNERSHIP E::] COUNTY-AGENCY U FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE n WITH AREA CODE <br /> Alamo CA 450 838- 1460 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER , Call (916) 323-9555 if questions arise. <br /> TY (TK) HQ FT4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br /> xs bl,Micale <br /> �] I SELF-INSURED ` 2 GUARAMEE S INSURANCE 4 SURETY BOND <br /> (] 5 LETTER OF CREDIT U 6 E%EA1?PON 93 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. l <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: Imo. IIL <br /> THIS FORM FIAS BEEN COMPLETED UNDER PENALT OF PE RK. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTSNAhIE iPRMTE I B SIGNATURE) ichar O e PPLICANTS TITLE GATE MONTHiDAY/YEAR <br /> Agent for Tri Star Homes , LLC Owner 5 /21 /97 <br /> LOCAL AGENCY USE ONLY <br /> bl <br /> I <br /> COUNTY u JURISDICTION # FACILITY # _ f <br /> Z�- IT 0 to to <br /> - - - -- - - - - - --- <br /> - -- -- <br /> LOCATION CODE - OPTIONAL iCENSUS TRACTa - OPTIONAL S'JPVISOR - DISTRICT CODE - OPTIONA MEMO <br /> r, ,,,. RA QCT OC Ainnine4oAMncn nVAT 1 R AST r41 OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br />