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C). STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 4 � O •c��•aw H'* COMPLETE THIS FORM FOR EMV n FACILtJ YISITE F i F MARK ONLY [_ � 1 NEW PERMIT I--� 3 RENEWAL PERMIT Cmm� 5 CHANGE OF INFORMATION F_ 7 PERMANENTLY CLOSED SITE ONE ITEM J 2 INTERNA PERMIT �— 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) F DBA OR FACILITY NAME NAME OF OPERATOR - Tri-Star Homes, LLC-----——_- _ ------Stephen Bailey __. ADDRESS NEAREST CROSS STREET PARCEL r(OPTIONAL) - ___.r_ _._. ..___. 1325-N. _Corral-Hal1ow..Rd.------.._ - ....Brno Hwy.---.._----�.--.- ---_ __---- --- CITY NAME 5?ATE ZIP CODE SITE pltONE•WITH AREA CODE Tracy, CA 95736 N/A ✓ Box ---- TOInDICATE F-1 CORPORATION L--j INDIVIDUAL [-.A PARTNERSHP [_j LOCAL AGENCY )COUNTY AGENCY [] STATE AGENCY .] FEDERAL-AGENCY DISTRICTS i TYPE OF BUSINESS C� 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN 0 OF TANKS AT SITE E.P.A. L( /opfioroa!) RESERVATION t p n 7 3 FARM IY_j 4 PROCESSOR X 5 OTHER OI�TRUST LANDS 2 GAC, 001 166584 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: AME(LAST,FI T) P` N WITH AREA CODE DAYS: NAME LAST,FIRST} Thorl Velly (209)839-2895 Hai�ey, Stephen (510)838--1460 --_ --PHONE0WLTH-AREAMCIS _ NIGHTS: NAME(LAST,FIRST) TT PHONE s WITH AREA CODE NIGHTS: NAME(LAST.FIRST] FSame as above Same as above PHONE I WITH AREA GOOF If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION _ Tri Star Homes, LLC MAILING OR STREET ADDRESS ✓ box i indieals {� INpIYIDUAI [] LOCAL-AGENCY 0 STATE-AGENCY P.O. Box 1056 [-]CORPORATION [ PARTNERSHIP COUNTY-AGENCY El FEDERAL-AGENCYCITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE Alamo, CA 94507 CA 94507 (510)838-1460 Ill, TANK OWNER INFORMATION-(MUST BE COMPLETED) j f NAME OF OWNER CARE OF ADDRESS INFORMATION T! _-_Tr-i_,5tar Hann_ 1--LLC F MAILING OR STREET ADORESS ✓ bom wndicala INDIVIDUAL rJ LCCAL-AGENCY L=] STATE AGENCY P.O. BOX 1056 1_-1 CORPORATION [Af PARTNERSHIP L]COUNTY-AGENCY [J FEDERAL AGENCY CITY NAMF STATE ZIP CODE PHONE i WITH AREA CODE Alamo, 24507 (510)838-1460 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if queslions arise. TY{TK) HQ 14.14 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓ Cor bindcate 1 1 SELF INSURED ( ] 2 GUARANTEE LETTER OF CREDITEj 1 INSURANCE 1-7-4 5uRETY BOND [_]6 EXEMPTION 99 OTHER I VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal no(ification and billing will be sent to the lank owner unless box I or II is checked. r-- L CI{ECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATION ANO BILLING: y T!IIS FORM 1!AS BEEN COMPLETED UNOER PENAL r OF PE RY,AND TO T4 BEST OF MY KN6WLEDGE,IS TRUE AND CORRECT ACI'LICANr'SNAME(PIIIN1G1)aSIGNATUnF) HiCharct '4foAt)ePLICANT'STITLE DATE MONTH)DAYNEAR J Agent for Tri. Star Homes,LLC Owner5/21/97 LOCAL AGENCY USE ONLY l I COUNIY4 JURISDICTION p FA]CIL11YA f - I-__ ._._ . ---- - - LOC:ATI(1N CODE �pPT10NA1 (CENSUS TRACT R �pAl10NAL SUPVISOR�DIS TRICT CODE �OPrlONAL F. , ' " I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION•IFORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. POW0 A 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A R6 I i