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eSpUR fs STATE OFCALIFORNIA ArP " car STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION! - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION JXX7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Saddle City Chevron - Station # 90302 MAILING OR STREET ADDRESS ADDRESS NEAREST CROSS STREET PARCEL # (OPrIONAL) 6241 W. Paddock Place Thorton Road 055-16-36 CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE Lodi CA 95242-9500 209 334-0975 TO DIC TE CORPORATION INDIVIDUAL = PARTNERSHIP Q LOCAL -AGENCY COUNTY -AGENCY 0 STATE -AGENCY FEDERAL -AGENCY DISTRICTS BUSINESS 1 GAS STATION O 2 DISTRIBUTOR = IF INDIAN I# OF TANKS AT SITE E. P. A. I. D. # (optional) :EO:F 0 3 FARM a 4 PROCESSOR 0 5 OTHER R✓ ESERVATION OR TRUST LANDS 5 ICAC001024176 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) Cecil, Dillon (209) 334-6613 PlAnIMPAW1111.1 ------ NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME Flag City, L.P. A Cal LTD Partnership CARE OF ADDRESS INFORMATION DATE MAILING OR STREET ADDRESS ✓ box IDindicate INDIVIDUAL Q LOCAL -AGENCY STATE -AGENCY 1820 W. Kettleman Lane Suite E Q CORPORATION PARTNERSHIP COUNrY-AGENCY FEDERAL -AGENCY CITY NAME STATECODE PHONE # WITH AREA CODE Lodi Ca 795241 209) 334-6613 III, TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Flag City, L.P. A Cal LTD Partnership__ MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY 1820 W. Kettleman Lane, Suite E E�:] CORPORATION [RTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE Lodi Ca 95241 209) 334-6613 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HQ 4 4 - 214 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box to indicate O 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND D 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ I'*'d J It. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED SI ATURE) APPLICANTS TITLE DATE Michael S. Ramos Owners/Agent "M�OyNaTW/D�AYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL I THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (5-91) FOR0033A-5