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eyO�R � <br /> STATE OF CALIFORNIA hep cO a <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a �° <br /> •C�(IFOR N.� <br /> COMPLETE THIS FORM FOR <br /> 1-1 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Iff 5 CHANGE OF INFORMATION t 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE J <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA12Vf�l��rr rl I�ECILITY#11194 NAMVF OPEpATkad <br /> �tjjr �� ara ra <br /> ADD <br /> S Tracy Blvd NGAF3ES-IffflW STREET PARCEL#(OPTIONAL) <br /> CITY racy STATE ZIP COD65376 166PE#,yYjT�j1REA CODE <br /> CA �y jf �jj�� �f <br /> ✓ BOX IMORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 4 000 03.5 A <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> SILVA, LARRY 1-206-"2-7160 PHONE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 13P Emergency Desk 1-800-274-3572 PHONE#WITH AREA CODF <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> t <br /> AME CARE OF ADDRESS INFORMATION <br /> First Interstate Bank of CA Iry Boxerbaum <br /> AILING OR STREET ADDRESS ✓ box to Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 345 Califom*a St, 8th Fir CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> TY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> San Francisco A 94104 415-773-7834 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Tosco Northwest Prop, 11, Inc. LARRY SILVA <br /> \MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 601 UNION STREET, STE 2500 0C CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SEATTLE I WA 98101 11-2M"2_71an <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4R]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate LJ 1SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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.❑ 111_Q <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) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ❑ Ia I3 1 e / <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) FOR0033A-5 <br /> 0 �ql� <br />