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es ua e <br /> • STATE OFCAUFORNIA to <br /> ' STATE WATER RESOURCES CONTROL BOARD sy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 'C�1110NN,. <br /> COMPLETE THIS FORM FOR EACH FACILITYISIfE <br /> MARK ONLY 0 t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Yellow Freight System Yellow Freight System <br /> ADDRESS NEAREST CROSS STREET PARCEL0(OPTIONAL) <br /> 4520 South Hwy. 99 Arch Road <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 <br /> TO INDICATE l�CORPORATION ] INDIVIDUAL I] PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY I]STATE-AGENCY ] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR O ,/ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(00imall <br /> RESE <br /> 3 FARM 4 PROCESSOR ® 5 OTHER OR TRUSTVATION LANDS —O— <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 /> Shinners, Steve (913) 344-3615 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> YFS Help Line (800) 395-5446 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Yellow Freight System Environmental Services — Steve Shinners <br /> MAILWGOR STREET ADDRESS ✓ box bindka% I] INDIVIDUAL ] LOCAL-AGENCY STATE-AGENCY <br /> 10990 Roe Avenue ®CORPORATION ] PARTNERSHIP ] COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> Overland Park KS 66211 (913) 344-3000 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Yellow Freight System Environmental Services <br /> MAILING OR STREET ADDRESS ✓ box b iMkaux INDIVIDUAL i] LDCAL-AGENCY ] STATE-AGENCY <br /> 10990 Roe Avenue CORPORATION PARTNERSHIP I]COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Overland Park KS 66211 (913) 344-3000 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 F4 - 0 0 0 9 0 6 <br /> V. 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.a II,® III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNA E) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> Cinthia K. Minenna Environmental Specialist 1010114- <br /> LOCAL <br /> 10 /q 9LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP7ONAL <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 /> FOR0033A R2 <br /> FORM A(390) <br />