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• A <br /> • + • c <br /> STATE OF CALIFORNIA r ° <br /> • n 9 <br /> STATE WATER RESOURCES CONTROL BOARD 11 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-� � (tA <br /> + )1 <br /> E Virg 1 IIYi EN..l AL HEAL <br /> COMPLETE THIS FORM FOR EACHFACILRY/SITE dl'. 1 /vL3'"1`V'` t <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMA ON [::] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOS <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> PACIFIC BELL SAME <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 345 N. SAN JOA UIN UE-042 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOCKTON CA 209-943-4016 <br /> ✓ Box <br /> TO INDICATE FXI CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR a 5 OTHER OR TRUST LANDS 1 3 CAT080029366 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(L T,FIRST) 3117EMERGENCY CONTROL CENTER 415-823-7777 ^ Q � <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) aD R 1 f <br /> 24 HRS/A DAY Ori (f <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> PACIFIC BELL SAME <br /> MAILING OR STREET ADDRESS ✓ box bIndicate E::] INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 2600 CAMINO RAMON, RM.# 2EO50 ®CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ';AN RAMON I CA 83 415-823-0560 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> PACIFIC 'BELL SAME <br /> MAILING OR STREET ADDRESS ✓ box to indicate E::] INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 1445 VAN NESS RM-# 236 [X-]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> FRESNO CA 93762 209-442-2288 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-[4-]-10131 1 1 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box ID indicate ® 1 SELF-INSURED 0 2 GUARANTEE [_1 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 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.[�:] It.❑ III.O <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(PRINTED&SIGNATU APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> GLORIA J. LOPEZ, STAFF ASSOCIATE AUG. 23, 1991 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FFTI Ob I 11 171 <br /> LOCATION CCOOD%OPTIONAL CENSUS TRA T#'OP_TIDNAL SUPVISOR-DIS�T� 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) 1/ FORIm33A-5 <br />