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STATE OF CALIFORNIA <br />K < STATE WATER RESOURCES CONTROL BOARD <br />�-- ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE o/ <br />L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME ( AST, FIRST) HONE # WITH AREA CODE <br />NAME OF OPERATOR <br />MCI Telecommunications <br />STATE <br />Corp - <br />PHONE # WITH AREA CODE <br />CITY E <br />ADDRESS <br />ZIPWIDE��6 <br />� 616 <br />ONE #WITH AREA COD <br />Af16)qq1 L15 <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />13850 <br />N.DeVries <br />Road <br />Hwy 12 <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Lodi <br />CA <br />95240 <br />✓ BOX <br />TO INDICATE <br />Ej? CORPORATION <br />INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY D COUNTY -AGENCY STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />BUSINESS = 1 GAS STATION 0 2 DISTRIBUTOR <br />0 ✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />rE <br />RESERVATION <br />3 FARM <br />4 PROCESSOR <br />E� 5 OTHER <br />OR TRUST LANDS <br />01 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS- NAME (LAST, FIRST) PHONE #WITH AREA ODE <br />L r Dn y/5 C?,5 <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME ( AST, FIRST) HONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II PROPFRTY OWNFR INFORMATION - (MUST RE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />[� CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />111. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NA E F OWNER <br />JVJp�-nl: <br />CARE OF ADDRESS INFO ATION <br />Lin a-LQCt� o <br />NG OR ST ET ADDRESS %� <br />fox <br />✓ b Indicate = INDIVIDUAL <br />= LOCAL -AGENCY 0 STATE -AGENCY <br />L-0, t/,5.5 <br />CORPORATION 0 PARTNERSHIP <br />= COUNTY -AGENCY FEDERAL -AGENCY <br />CITY E <br />STAJE6 <br />� <br />ZIPWIDE��6 <br />� 616 <br />ONE #WITH AREA COD <br />Af16)qq1 L15 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 - 10 1 21 41 71 51 0 <br />V. PETROLEUM UST FINANCI L RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box b indicate 1 SELF-INSURED E:1 2 GUARANTEE D 3 INSURANCE 4 SURETY BOND <br />(� 5 LETTER OF CREDIT I] 6 EXEMPTION = 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. A. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. E] II. E:] III. <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 & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # C` mp # JURISDICTION # FACILITY # n 1 <br />39 MCITEI3 0 0 1 5 4 7 (/� <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL U\V qv <br />99 23.30 321 <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) FOROM3A-5 \ <br />