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0 .ounces <br /> � c <br /> STATE OF CALIFORNIA A! <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W dam, a <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 f 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME QF OP RATOR <br /> Freeway Shell Austin Haters <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 880 Victor Road Beckman Road <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> LodiyY CA 95240 209-368-3755 <br /> ✓BOX '�£ORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY lD COUNTY-AGENCY' (] STATE-AGENCY' a FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 owner of UST is a public a=,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS fZ 1 GAS STATION 2 DISTRIBUTOR 0 RESV IF INDIAN ERVATION #OF TANKS T SITE EC P.A. 1.D.# tional) <br /> Q 3 FARM Q 4 PROCESSOR O 5 OTHER 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 /> Tracy Vossbera_ 209-368-37.55 Austin Waters 209-368-3755 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> EQUILON ENTERPRISES, LLC Aura Mattis <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> P.O. BOX 8080 Q3 CORPORATION a PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> - O6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> E UILON ENTERPRISES, LLC Aura Mattis <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 8080 M CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> jhjjTjrL7 r 94551 925-335-5026 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - 113 1 11 0 2 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT Q 6 EXEMPTION O 7 STATE FUND <br /> =8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.❑ <br /> T S RM HAS EN COMPLETtD UNDER P LTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> It <br /> TANK NA TED& ) T K OWNER'S TITLE DATE NTHIDAY <br /> C <br /> LOC L AGEkk USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,UNLEWIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRIW <br /> STORAGE TANK REGULATIONS <br />