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�I r,6oV LACES STATE OF CALIFORNIAr `°s STATE WATER RESOURCES CONTROL BOARD a �, UNDERGROUND STORAGE TANK PERN IT APPLICATION- FORM A ' 4� ' C�l�F pq Nin COMPLETETHIS FORM FOR EAC FACILITYlSITE MARK ONLY I i'i 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM'PERMITI 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE aj I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME O OPERATOR Tri Star Homes, LLC Stephen Bailey ADDRESS NEARE5 r CROSS STREET PARCEL#IOPTlONALI 1325 He Corral Hallow Pd Bv rcrl CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Tracy, CA 1 95736 N/A ✓ BOX ,met - TO INDICATE I�CORPORATION l� INOIVIDUAL i ni PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 71 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR - 0 ✓ IF INDIAN I#OF TANKS AT SITE Eryry,API/,+A,X111.D.#(optional) RESATION 3 FARM 4 PROCESSOR � 5 OTHER OR RUSTVLANDS CAC 001166584 EMERGENCY CONTACT PERSON (PRIMARY).,,,, , EMERGENCY CONTACT PERSON (SECONDARY) -optional DAYS-1 FI� l � WITH AREA CODE DAYS; F ?s horpe, el (20ry)V395 Ril , teplen (510)838-1460 g P14QNI #WITH AR NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA;CODE NIGHTS: NAME(LAST,FIRST) Same as above Same as above PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION Tri Star Homs, LLC MAILING OR STREET ADDRESS ✓ box indicate 0 INDIVIDUAL LOCALAGENCY0 STATE-AGENCY P♦O• Box 1056 [D CORPORATION LX PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Alamo, CA 94507 CA 94507 (510)838-1460 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) y NAME OF OWNER CARE OF:ADDR�SS INFORMATION _ Tri Star Homes LLC MAILING OR STREET ADDRESS ✓ boy indicate INDIVIDUAL 0 LOCAL-AGENCY � STATE-AGENCY P♦0. Box 1056 [] 'O PORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Alamo, C 94507 � (510)838-1460 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L �- _j V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED , ✓ box to indicate f� 1 SELF-INSURED [ 2 GUARANTEE 3 JNSURANCF 4 SURETY BOND CI 5 LETTFROFCRFDIT 6 EXEMPTIOIi 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and bil ing 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 NOTIFICATION 3 AND BILLING: I. IL III. THIS FORM HAS BEEN COMPLETED UNDER PENALT OF PEQbVR.Y,AND TO TIJE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTEC&SIGNATURE) > t% C PPLICANT'S TIT E DATE MONTHIDAYlYEAR Agent for TrieStar Homs,LLC Ooner 5/21/97 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL f CENSUS TRACT# -OPTIONAL SUPV SOq-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. FORI, A(12-91) FILE THIS FORM WITH-THE LOCAL AGENCY IMPLEMENTING THE L NDERGROUND STORAGE TANK REGULATIONS FOR0033A-116