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4 <br /> ��5015 C. f0 <br /> STATE OF CALIFORI IIA '. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> 0 <br /> COMPLETE THIS FORM FOR EX H FACILrrYlSITE <br /> MARK ONLY 1 NEW PERMIT E:l 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � _ EFiMANENTLY CLOSED SITE <br /> ONE ITEM2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE VV! <br /> f. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME !I NAME OF OPERATOR <br /> Tri Star Homes LLC Stephen Bailey <br /> ADDRESS NEAR ST CROSS STREET I PARCEL x(OPTIONA 4 <br /> 1329 N. _�yrnp Hury <br /> CIN NAME i STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> Tracy, I CA 95736 N/A <br /> TO INDICATE 11 CORPORATION © INDIVIDUAL U PARTNERSHIP '� LOCAL-AGENCY <br /> CI COUNTY-AGENCY STATE-AGENCY C71FEDERAL-AGENCY <br /> DISTRICT <br /> TYPE OF BUSINESS F__!, 1 GAS STATION 2 DISTRIBUTOR 0 RE./ INDIAN <br /> SEtRVATTION xOF TANKS AT SITE E.1IP.A. l�I.D.x(op7ional} <br /> 3 FARM 4 PROCESSOR ED 5 OTHER R TRUST LANDS 2 CAC 00 1 i <br /> 166584 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AME(LAST,FIR T) PHONE x WITH AREA CODE DAYS: NAME LAST,FRST) <br /> her e FIR <br /> {209)839-2895 Bailey, Stephen (510)838-1460 <br /> p , CNF a WITH ARRA(`nr1r- <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGH S: NAME(LAST,FIRST) <br /> Same as above Same as above aH <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> Tri Star Homes LLC <br /> MAILING OR STREET ADDRESS `� y.budlpta © INDIVIDUAL 0 LOCAL-AGENCY ©STATE-AGENCY <br /> P.O. BOX 1056 © ORPORATSON Q PARTNERSHIP C COUNTY-AGSNCY Q FEDERAL-AGENCY <br /> CITY NAME STAI E ZIP CODE PHONE x WITH AREA CODE <br /> Alamo, CA 94507 CA 94507 (510)838-1460 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> �-dr7 CAR OF ADDRESS INFORMATION <br /> �,�, il_�+ i .-u+✓ ✓ box to i11diWtg <br /> MAILING OR STREET ADDRESS INDIVIDUAL fEj LCCAL-AGENCY [�STATE-AGENCY <br /> P.O. BOX 1 056 Q CORPORATION = COUNTY-AGENCY OUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHCNE x WITH AREA CODE <br /> Alamo CA 4507 (510)838-1460 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPL EQ)-IDENTIFY THE METHODS) USED <br /> ✓ <br /> box bindicate <br /> I SELF,INSURED L✓2 GUARANTEE = 3INSURANCE L-3 4 SURETY BOND <br /> C.I 5 LETFEROFCREDIT v 6 EXEM ION [771 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box 1 or 11 is checked. <br /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICA IONS AND BILLING: I.�! II-[7X Ili, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALT OF PEWRY,AND T THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR INTELD&SIGNATURE) Richar O O PLICANT' TITLE DATE MONTH;DAYNeAR <br /> Agent for Tri Star Homes,LLC Owner 5/21/97 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION# FACILITY# <br /> LOCATION CODE OPrlONAC 3CENSUS TRACT x -OPTIONAL S UPVISOR-DISTRICT CODE -OPTIONAL I <br /> I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE.PERMIT APPLICATI N- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> STORAGE TANK REGULATIONS <br /> �pRM A 1;2.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T E UNDERGROUND <br /> FOR0373A F6 <br />