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STATE OF CALIFORNIA `/ 0 STATE WATER RESOURCES CONTROL BOARD s' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A m `' . yam.. i•I COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION X2 7P MANENTLV ONE ITEM � 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR RTR Facility Stockton r r or ADDRESS NEAREST CROSS STREET PARCEL#(O 5000 So. Airport Way Arch Way CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Stockton CA 209-946-6310 TOINDICATE I-3 CORPORATION E-1 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY {FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR E--i ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apfianal) ESE O 3 FARM 4 PROCESSOR R� 5 OTHER ORTRUSTVLAANDS 1 CAC000965360 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) RIZZO TONY 916-551 -3406 PHONE 0 WITH AREA rQQP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) �3406 PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION U S DEPARTMENT OF TRANSPORTATION TONY RIZZO MAILING OR STREET ADDRESS ✓box liars O INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY 10275 OLD PLACERVILLE ROAD p CORPORATION O PARTNERSHIP Q COUNTY-AGENCY IX FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Sacrament California CA 95827-3044 916-551 -3406 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Same as above II MAILING OR STREET ADDRESS ✓ box binObam INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box blMbak r}�q 1 SELF.INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND LJ 5 LETTEROFCREDIT 0 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank own mess box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 0 II.F—] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KydWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR THOMAS E. MURRAY er' s Age 7/28/94 j, g LOCAL AGENCY USE ONLY W COUNTY# JURISDICTI N# FACII�LITYY# / LOCATION CODE - TIONAL CENSUSTRACT#-OPTIONAL SUPVISOR-DISTRIC DE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS TH ION ONLY. FORM A Is 91) FOR W33A 4... V40.