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^`g0,11 •�s c <br /> I STATE OF CALIFORNIA `- he °f <br /> STATE WATER RESOURCES CONTROL BOARDAb <br /> '' 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A �', <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> AT&T Communications AT&T Communications <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 110 West Turner Rad �o Haven Lane <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lodi CA <br /> ✓BOX Q CORPORATION INDIVIDUAL r__1 PARTNERSHIP F-I LOCAL-AGENCY COUNTY-AGENCY` Q STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '9 owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR <br /> t/IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR ❑ 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AT&T Communications <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 227 West Monroe, Suite 2240 l7 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMECODE PHONE#WITH AREA CODE <br /> Chicago STATE ZIP 60606 888-835-5347 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> AT&T C.ommunicatio <br /> MAILING OR STREET ADDRESS &/ box to indicate Q INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 2.27 West Monroe, Suite 2240 Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> Chicago 11 IL 60606 888-835-5147 <br /> IV.BOARD OF-EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. " <br /> TY(TK) HQ F414-]_1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 i SELF-INSURED 0 2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 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.❑ fl.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> i <br /> TANK OWNER'S NAME INTED&,SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL J <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 /> FORMA(6-95) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRq*STORAGE TANK REGULATIONS <br />