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• � cyoua e.x <br /> STATE OF CALIFORNIA ^e `t <br /> STATE WATER RESOURCES CONTROL BOARD i g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w��, v; <br /> .n f. o <br /> O.M,. <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY u 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 /> 1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) - <br /> DBAOR FACILITY NAME NAME OF OPERATOR <br /> Tracy Marines Sales __ _ <br /> ADDRESS NEAREST CROSS STREET PARCEL A CFBONAL) <br /> 2,351 Toate Rnad <br /> CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> TrAc CA 95376 209 835-6565 <br /> ✓ BOX XX <br /> TOINDICATE XXCORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE AGENCY 771 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR =7 ✓ IF INDIAN Itt OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION 1 2 <br /> 0 3 FARM 4 PROCESSOR ®C 5 OTHER OR TRUST LANDS CAC 000 764 064 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) 209 956-0264 <br /> _ _ Little. William 209956— w li ' aPEON "WITH AREA Gnnp <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 209 996-0476 <br /> Joe Toste Jr. 209 835-4476 Joe Toste Jr. PHONE 9 WITH AREA Conp <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Joe Toste Jr. — Toste Farms 2460 Toste Road, rac CA 95376 <br /> MAILING OR STREET ADDRESS ✓ Wx Inindicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> 2460 Toste Road CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Trac 6 CA 9537 209 835-4476 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Toste Farms 2420 Toste Road, TRac , CA 95376 <br /> MAILING OR STREET ADDRESS ✓ box b ndlcate O INDIVIDUAL = LOCAL-AGENCY 17 STATE-AGENCY <br /> 2420 Toste Road, T kXCORPORATION 0 PARTNERSHIP E-j COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Trac CA 95386 299 8350 4476 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> i TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ w ainakate f 1 1 SELF INSURED E] 2 GUARANTEE 3 INSURANCE []4 SURETY BOND <br /> L�5 LETTEROFCREDIT 6 EXEMPTION 93 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: LD 11.kit III.® <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTEDB SIGNATU ) APPLICANTSTITLE DATE MONTH/DAYNEAR <br /> William Little 06 Geologost October 07 1H99 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> l l ALT- <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> _.... � � FOR0033AR6 <br />