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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 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT :R6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ( q DBA OR FACILITY NAME NAME OF OPERATOR California Water Service ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 1602 E. Lafayette St . Wilson Way CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 11 ✓BOX Q CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP EX LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' TO INDICATE DISTRICTS I owner of UST is a public agency,complete the following:name ol supervisor of division,section or office which operates the UST TYPE OF BUSINESS a 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 CAL000046942 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 Bailey, Scott (209)464-8311 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE Bailey, Scott (209)464-8311 II. PROPERTY OWNER INFORMATION-(MUST BE COA4PLFTFD1 NAME CARE OF ADDRESS INFORMATION ServiceCa,Lifornia Water MAILING OR STREET ADDRESS ✓ bcx to r ca'a 0 IKONOUAL EX-1 LOCAL-AGENCY Q STATE-AGENCY 1609, TP,- Tiafayetti- St CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE Stockton CA 95203 (209)464-8311 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION California Water Service MAILING OR STREET ADDRESS ✓ boxio indicate Q INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY 1602 E. Lafayette ST. 0 CORPORATION (] PARTNERSHIP a COUNTY-AGENCY a FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Stockton, CA 95203 � (029)464-8311 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - ❑ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE 3 INSURANCE =4 SURETY BOND a 5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 6 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: I.❑ it.[:N III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJ ., N O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED 8 SIGNATURE) 'if TAN NER'S TITLE DATE MONTIUDAYIYEAR California Water Service By Contractor 11/13/00 LOCAL AGENCY USE ONLY 7f COUNTY# JURISDICTION# FACILITY# m hI qT� LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTI NAL SUPVISOR-DIS/TRR)ICT CODE -OPTIONAL Y V 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 Y&HE LOCAL AGENCY IMPLEMENTING THE UN�D�E/RJG`R/ODUJ RAGE TANK REMIL]A'yTI914�, FORMA(6-95) / _/�. _ 'r ` ;J3q/ l\J ,I�40ZO -s"'V' I�`I//- t l``77_