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a— <br /> MARK <br /> STATE OFCALIFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE /J <br /> ONE REM 0 2 INTERIM PERMIT E::] < AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Stockton Metropolitan Airport-Fuel Ke lock County of San Joaquin <br /> ADDRESS Facility NEAREST CROSS STREET PARCELA(OFMLL) <br /> 7080 C.E. Dixon Street Lockheed Court <br /> CITY NAME STATE TZIP CODE SITE PHONE&WITH AREA CODE <br /> Stockton CA 1 95206 None <br /> TO INDICATE �CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q DISTRICTS' <br /> ®COUNTY-AGENCY' f�STATE-AGENCY' =FEDEMAGENCY' <br /> D6TR CTS' <br /> •M owner d UST 4 a pubAc agency.ooeplale the IOAowing:name d Supervkor o1 tlivi6bn,section,or bnice which operates the UST Dan DeAngelis <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q R SERVAT/ IFF INNDIAAN a OF TANKS AT SITE I E.P.A. 1.D.0(cp&pMpON <br /> Q 3 FARM Q a PROCESSOR LX] 5 OTHER OR TRUST LANDS One V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional <br /> DAYS:NAME(LAST.FIRST) PHONE t WITH AREACODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> DeAngelis, Dan 209 468-4700 1 Brookg, Michael 20 468-4700 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> DeAngelis, Dan (209) 957-4119 Brooks, Michael (209) 478-9034 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> County of San Joaquin <br /> MAILING OR STREET ADDRESS ✓batblMN k, INDIVIDUAL ED LOCA4AG#NCY 0 STATE-ACfV <br /> 5000 S. Airport Way, Room #202 INCORPORATION =PARTNERSHIP KI OOUNTYAGENCY OFEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> Stockton CA 95206 (209) 468-4700 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> County of San Joaquin <br /> MAILING OR STREET ADDRESS ✓ box to ntic" l--I INDIVIDUAL (] LOCAL-AGENCY L-1 STATE.AGENCY <br /> 5000 S. Airport Way, Room #202 =CORPORATION = PARTNERSHIP IZ COUNTYAGENCY =FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> Stockton CA 95206 209 468-4700 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ M44- - 0 2 4 5 5 9 <br /> aV. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓buxbindicas [1 1 SELF-INSURED ED 2 GUARANTEE 0 3 INSURANCE O F SURETYBOND <br /> g <br /> 1715 LETrEROFCREGT 0 6 EXEMPTION 0 92 OTHER <br /> H 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 /> DICATING <br /> ICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND <br /> L D <br /> CHECK ONEBOXBOFORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST BILLING: RUI II <br /> OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ECT <br /> OWNER'S NAME(PRINTED&SIG NED OWNER'S TrTLE DATE MONTHIDAWYEAR <br /> Dan DeAngelis Airport Manager March 14, 1994 <br /> LOCAL AGENCY USE ONLY <br /> COLI JURISDICTIONR FACILITYf - <br /> Aww ZZ I Z131 oo <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3'93) <br />