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• STATE OF CALIFORNIA • •`�O ..'`o <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A tl� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT [�] 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> JSG Trucking, Inc. JSG Truckin Inc. <br /> 1q400 N. Hwy 99 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> Acampo, CA 95220 (209)368-8815 <br /> ✓BOX CORPORATION Q INDIVIDUAL I] PARTNERSHIP LOCAL-AGENCY f�COUNTY-AGENCY' Q ' <br /> TO INDICATE DISTRICTS STATE-AGENCYf� FEDERAL-AGENCY' <br /> H ovmerd UST lsapub[cagenry,complete the blbwing:named supervsord dn6ron,sMion or office which operetes the UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN #OFTANKS AT SITE E.P.A I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR ] 5 OTHER RESERVATIONORTRUSTLANDS 1 CAL 000008107 <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 /> Giammona Joe (209)368-8815 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AgEA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> JSG Trucking, Inc. Joe Gianmiona <br /> MAILING OR STREET ADDRESS ✓ box tokcicate =INDIVIDUAL LOCAL-AGENCY INSTATE-AGENCY <br /> 19400 N. Hwy 99 EMCORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Acam o CA 95220 (209)368-9,915 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> JSG Trucking, Inc. Joe Giammona <br /> MAILINGOR STREET—ADDRESS ✓ boxto Wmi. Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 19400 N. Hwy 99 g]CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boxlcin0'raM [=1 1 SELF-INSURED [::] 2 GUARANTEE O 3 INSURANCE Q 4 SURETY BOND 5 LETTER OFCREDR Q 8 EXEMPTION O 7 STATE FUND <br /> EX 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q9STATE RIND&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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) JSG 'ng TANK OWNERS TITLE DATE MONTHIDAWYEAR <br /> By R Thorpe/ Contractor Owner 4/14/99 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77ONAL SUPVISOR-DISTRICT CODE -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 /> FORMA(6-95) OWNER MUST FILE THIS FOOTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR ff STORAGE TANK REGULATIONS <br />