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I <br /> eSpUR �9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a�� n <br /> "CSI IfOM N`' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F_� 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 7 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) C-/ <br /> NAMF <br /> OBA6I}F/ I�JTYr�la�1FCILITY#11193 im enner <br /> ADD92022 W. Hammer Lane NEAREST CROMfPEET PARCEL#(OP ZONAL) <br /> CITY Aockton STACEA ZIPN5209 LV�P:7.7/ TkI,QREACODE <br /> j✓ BOX <br /> TO INDICATE MORPORATION F-1INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY L`JUUODU FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> 3 6AL 000 039 100 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> SILVALARRY 1-206-442-7160 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> BP Emergency Desk 1-800-274-3572 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAE CARE OF ADDRESS INFORMATION <br /> T. W. B. Development <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY E:] STATE-AGENCY <br /> 8102 Kelly Drive Ste J CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 95209 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Tosco Northwest Prop. I, Inc. LARRY SILVA <br /> MAIL ZP R STRE STREET, STE 2500 ✓ box to indicate � INDIVIDUAL 0 LOCAL-AGENCY � STATE-AGENCY <br /> (� CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SEATTLE I WA 98101 1-206-442-7160 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4—f-4]- 0 13 16 12 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate XX 1 SELF-INSURED (]2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> = 5 LETTER OF CREDIT Q 6 EXEMPTION 0 99 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. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> CHESTER BENNETT RETAIL ENGINEER <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# k_ <br /> al� z, �� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) 'E FOR0033A-5 <br />