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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE MARK ONLY ONE REM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ORA OR FACILITY NAME NAME OF OPERATOR Pacific Bell PARCEL#(OPTIONAL) ADDRESS NEAREST CROSS STREET 907 Lincoln Road Lincoln Road STATE ZIP CODE SITE PHONE#WITH AREA CODE CITY NAME Stockton CA 95207 20 474-4300 . ./ BOXCORPORATION 0 INDIVIDUAL (]PARTNERSHIP 0 LOCAL- DISTRICTS' COUNTY•AGENCY- (]STATE-AGENCY' =FEDERAL-AGENCY' TO INDICATE DISTRICTS' If owner d UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST V IF INDIAN 1TYPE OF BUSINESS ❑ i GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) Q 3 FARM 4 PROCESSOR [M 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Quinones D. 209 474-4300 F .. - 7777 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS, N ME(LAS ,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME Pacific Bell - Pernit Desk Louana JUribe MAILING OR STREET ADDRESS 26,46 Watt Avenue ✓box b indicate = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY P .O. BOX 15 0 38 Sili CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE CA 9 5 8 51 PHONE#WITH AREA Sacramento 11 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME OF OWNER Same as above (II) MAILING OR STREET ADDRESS ✓box bindicate 0 INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY F-1 CORPORATION [] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F414- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box b Indicate F-1 1 SELF-INSURED 0 2 GUARANTEE ED INSURANCE 1�4 SURETY BOND O 5 LETTER OF CREDIT O 6 EXEMPTION 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: I.❑ Il.x] Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY Record I.D. COUNTY# JURISDICTION# FACILfrY#� � ❑ I❑ I 1 I l LOCATIOONi DE -OPTIONAL CENS 2 3 8 O OPTIONAL SUPVISOR 3 DISTRICT CODE -QPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGI TANK REGULATIONS FOM3A47 FORM A(3193) `