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STATE OF CALIFORNIA • `� <br /> STATE WATER RESOURCES CONTROL BOARD �" . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 4. <br /> • C�(IIORNt' <br /> MARK ONLY ❑ 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 /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (� <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> SS#30877 James J. McCarthy <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1700 East Yosemite Avenue Highway 99/Highway 12 <br /> CITY NAME STATE I ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 95336 2098237676 <br /> BOX ® CORPORATION ❑INDIVIDUAL ❑ PARTNERSHIP ❑ LOCAL-AGENCY ❑ COUNTY-AGENCY ❑ STATE AGENCY ❑FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> 'If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#/optional/ <br /> [13 FARM ❑ 4 PROCESSOR[15 OTHER RESERVATION 2 <br /> OR TRUST LANDS <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 /> James J. McCarthy2098237676 <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME:(LAST,FIRST) PHONE#WITH AREA CODE <br /> James J. McCarthy 209/576-0979 <br /> II. PROPERTY OWNER INFORMATION -MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Je,.t,­xt. ❑INDIVIDUAL ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> P.O. Box 52085 ®CORPORATION ❑PARTNERSHIP ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Phoenix AZ 85072 (602)437-0600 <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME CARE OF ADRESS INFORMATION <br /> Tosco Corporation Environmental Com liance <br /> MAILING OR STREET ADDRESS J box to indicate ❑INDIVIDUAL ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> P.O. Box 52085 19 CORPORATION ❑PARTNERSHIP ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NANIt 51AIE I 7IFr5Dr-- PHONE#WITH AREA COu� <br /> Phoenix AZ 85072 (602)437-0600 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916) 322-9669 if questions arise. <br /> TY (TK) HQ [_ZT__4] 1 0 3 6 2 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br /> J box to indicate ® 1 SELF-INSURED ❑ 2 GUARANTEE ❑ 3 INSURANCE ❑ 4 SURETY BOND <br /> ❑ 5 LETTER OF CREDIT ❑ 6 EXEMPTION ❑ 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> DON ESPERSON DIRECTOR OF COMPLIANCE APRIL 1, 1997 <br /> LOCAL AGENCY USE ONLY 710 <br /> COUNTY# JURISDICTION # FACILITY # <br /> EE I <br /> LOCATION CODE-OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL W ._ „• <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. <br /> FORM A(3/93) FOR0033A-87 <br />