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id q,�CN)y w'�d•.. c STATE OFCALIPoRMA STATE WATER RESOURCES CONTROL BOARD i o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , o COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SI + ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Stockton Metropolitan Airport-Fuel Ke lock County of San Joaquin ADDRESS Facility NEAREST CROSS STREET PARCEL 0(OPfONAD 7080 C.E. Dixon Street Lockheed Court CITY NAME STATEZIP CGOE SITE PHONE 0 WITH AREA CODE Stockton CA 95206 None I/Box TO INDICATE ED CORPORATION O INDIVIDUAL O PARTNEASHP ED LOCAI.AGFNOY QC] COUNTY#GENCY' O STATE.AGBICY' O F®ERAL#GENCY' 'I own«d UST b a public a amour the 1 DISTHICT$' >HI «.y. obw'vi#:nanrdSuperv'NoratlNiNbn.eenbn,«o#im whkh aperatw Ns UST Dan DeAngelis TYPE OF BUSINESS ❑ I GAS STATION Q 2 DISTRIBUTORQ RESERVATION IF INDIAN is OF TANKS AT SITE E.P.A. I.O.#NpN«WI ❑ 3 FARM ❑ A PROCESSOR ® 5 OTHER OR TRUST LANDS One EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal DAYS:NAME(UST,FIRST) PHONE N WITH AREA COTE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DeAn ells Dan 209 468-4700 Brook Michael 209 468-4700 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DeAngelis, Dan (209) 957-4119 Brooks, Michael (209) 478-9034 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION County of San Joaquin •l J�(f' MAILING OR STREET ADDRESS ✓ b INDIVIDUAL UXAL-AGFNCY Q STATE-AGENCY 5000 S. Airport Way, Room #202 O CORPORATION PARTNERSHIP ®CO NITYAGENCY O FMEMLAGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CGDE Stockton CA 95206 (209) 468-4700 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION County of San Joaquin MAILING OR STREET ADDRESSn ✓barbwKaN 0 INDNIDUAL C3 LOCAL AGENCY 0 STATE AGENCY N 5000 S. Airport Way, Room #202 O CORPORATION 0 PARTNERSHIP CO COUNIYAGENCY O FEOEPALAGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE Stockton CA 1 95206 209) 468-4700 �j IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-[44- - 0 2 4 5 5 9 aV. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓bar bbNpM ®I SEURNSURED El 2 GUARANTEE ED 3 INSURANCE 0 A SURETY BOND 5 LETTEROFCREDIT 0 6 ExEMPnON Q 99 OTHER N A. 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 BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ IN. THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED OWNERS TITLE DATE MONTWOAYNEAR Dan DeAngelis ' Airport Manager March 14, 1994 LOCAL AGENCY USE ONLY COUNTY III, JURISDICTION# FACILITY! Yj aj Z,,/, 00 �� LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT70ML �1 D THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMITAPPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM V THE LOCAL AGENCY IMPLEMENTING THE UNOERGROUF -ORAGE TANK REGULATIONS FORMA(393)