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eS�Vn � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BO a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w s <br /> •C�IIFOR N,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 1?9(5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA I TY NAME OF OPERATOR <br /> �`I ��, MILITY#11192 Denise White <br /> ADD NEAREST Country Club Blvd NEAREST CROSSers ny PARCEL#(OPTIONAL) <br /> CIN AME STATE FZIIP CODE SITE PHONE#WITH AREA CODE <br /> tockton CA 95204 209-943-2082 <br /> ✓ BOX ,�,c,� <br /> TO INDICATE EMORPORATION (] INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE L.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <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 11-2116-449-7160 PHONE#WITH AREA rnr)F <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> First Interstate Bank of CA Iry Boxerbaum <br /> IA�� MAILING OR STREET ADDRESS ✓ boxbindcate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> '! M California St, 8th Fir CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> San Francisco A 10415-773-7834 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Tosco Northwest Prop- 1, Inc- I ARRY .0,11 VA <br /> MAILING OR STREET ADDRESS ✓ box b indicateINDIVIDUAL <br /> 0 � LOCAL-AGENCY STATE-AGENCY <br /> 601 UNION STREET, STE 2500 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SEATTLE I WA Q8jnj 160 _j <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> Y(TK) HQ 4 4 - Q�2T4� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> y[� - 2 GUARANTEE 3 INSURANCE 4 SURETY <br /> BOND <br /> ✓ boxbindicate 1 SELFINSURED 0 � <br /> 5 LETTER OF CREDIT 0 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. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> ___7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m a I'/& <br /> LOCATION CODE -OPTIONAL"IOI` ICENSUS 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 A G OF SITE INFORMATION ONLY. <br /> FORM A(5-91) fFOR0033A-5 <br /> BHl7BA�A <br />