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t � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED,SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 2- 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR AT&T Communications AT&T Communications ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 110 West Turner Road Wood Haven Lane CITY NAME STATE 7 CODE SITE PHONE#WITH AREA CODE Lodi CA ✓BOX ]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY D COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS ff owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR 5 OTHER RESERVATION 0 � OR TRUST LANDS 2 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AT&T Communications MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 227 West Monroe Suite 2240 §0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Chicago IIL 60606 888-835-5347 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION AT&T Communications MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY 227 West Monroe, Suite 2240 ®CORPORATION PARTNERSHIP (] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Chicago IL 60606 888-835-5347 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise, TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND D 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing 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 NOTIFICATIONS AND BILLING: 1.® II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S N77= ATURE) TANK OWNER'S TITLE DATE MONTHf AYNEAR Q3 QG ✓�2 Z��G�/N6 I�nl�/.v P' zS� qy LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY aR Fm 1 ) -7I LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 75PVISOR.DISTRICT CODE -OPTIONAL 3Bt THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS