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� STATE OF CALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD W wg :a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORMA . ,, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �"'[°""�� <br /> MARK ONLY <br /> 0 t NEW PERMIT O 3 RENEWAL PERMITINFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ® 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Broadb se MCEL#(OP(OPTIONAL) <br /> ADDRESS NEAREST CROSS STREET <br /> 1130 N Main STreet Louise Avenue <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 209-239-0665 <br /> ✓ BOX [ CORPORATION O PARTNERSHIP 0 LOCAL.AG CY COUNTYAGENCY• [-ISTATEAGENCY• =FEDERAL-AGENCY' <br /> TOINDICATE <br /> •ff owner d UST la a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS T GAS STATION 2DISTRIBUTOR 0 RE./ IF INDIAN <br /> SERVATION #OF TANKS AT SITE P.A. I.D.#(apo'onalJ <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE f WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Ila <br /> 1-800-232-5923 <br /> NIGHTS:ILtNAME(LAST OR d 209-239-0665 PHONE f WH AREA CODE NIGHTS: NAME(IAST l Pa PHONE#WITH AREA CODE <br /> 510-942-1286 <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Correll Properties <br /> MAILING OR STREET ADDRESS ✓ boa loIndcate = INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> 285 Industrial WAy XI CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY O FEDERALAGEWY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Woodland, CA 95695-6099 916-661-0104 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Broadbase Inc. <br /> MAILING OR STREET ADDRESS `� box= INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGEWY <br /> C.ilgc) Danville Blvd. 9270 <br /> ITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Alamo CA 94507 510-838-1172 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- - 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa to Indicate t SELF INSURED '2 GUARANTEE L-1 3INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 6 EXEMPTION 0 99 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: I.O it.O III. <br /> THIS F R H BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OW R DB SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> Donald W. Fowler President 12/30/93 <br /> L AGE <br /> COUNTY# JURISDICTION <br /> O�N# FACILITY• <br /> 7"— <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SLIPVISOR-DISTRICT CODE -OP <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOHa aARr <br /> FORM A(3/93) <br /> • /I <br />