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STATE OF CALIFORNIA `'e `'t <br /> STATE WATER RESOURCES CONTROL BOARD 3,off e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �>p <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ED NEW PERMIT O 3 RENEWAL PERMIT I�4 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PER 4 AMENDED PERMIT J� 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Sunn side Produce Mike Manzer <br /> ADDRESS NEAREST CROSS STREET PMCEL#(OPTA)NAu <br /> 8960 W. Walnut Grove Rd. 1-5 <br /> CITY NAME STATE ZIP COCE SITE PHONE#WITH AREA CODE <br /> Thornton CA 95686 209-794-2720 <br /> TO/ BOX <br /> XTE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY [_1COUNTYAGENCY 0 STATE-AGENCY E-1FEDERALAGENCY <br /> DISTRI <br /> TS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ./ IF INDIAN #OF TANK5 AT SITE E.P.A. I.D.#(aptimall <br /> ® D RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 CAC001 381 1 92 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Manzer, Mike 209-794-2720 McHugh, John 20 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Manzer, Mike 209-794-2720 McHugh, John 20 - - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Barnyard Corp c/o Nelson & Co. <br /> TIl,61GJJR KREERADDQQll ✓ boa blMkats 0 INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> 144.-88''.JD 11VV a1Son .St. Eg CORPORATION = PARTNERSHIP =COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 95202 209-464-9827 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Barnyard Corp c/o Nelson & Co. <br /> MAILING OR STREET ADDRESS ✓ bc4bl dtl 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 1 435 N. Madison St. CORPORATION I= PARTNERSHIP Q COUNTY-AGENCY I= FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE TPHONE#WITH AREA CODE <br /> Stockton CA 95202 209-464-9827 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HO F4714]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box blMicau EXI SELF-INSURED E-3 2 GUARANTEE 0 3 INSURANCE O 4 SUR' <br /> IY BOND <br /> ED 5 LETTEROFCREOIT F__l 6 EXEMPTION 0 W 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: <br /> THIS FORM HAS BEEN COMPLETED ODER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGAPPLICANTS TITLE DATE MONTWDAYNEAR <br /> NATU <br /> Keith A. Talli Agent 12/15/98 <br /> LOCAL AGENCY USE ONLY Tb A 3 175 <br /> COUNTY�# JURISDICTION# /�L /FACILITY#D4 O 3 <br /> V I it - 6P60111 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT0 -OP NAL 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(5-91) FORMnA5 <br />