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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOAR <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE •�� olo <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED _ <br /> ONE REM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 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 /> ADDRESS NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> 19400 N. Hwy 9.9 bridge Rd. <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> Acampo, CA 90220 (209)368-8815 <br /> ✓BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTYAGENCY' O STATE AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'N aemer of UST N a publcegenry,m Wl.the h M.etg:namadstgeruiserd drvecn,sMbnadlce which aperales the UGT <br /> TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN N OF TANKS AT RVAnON SITE E.P.A. I.D.A(optimal) <br /> Q 3 FARM D a PROCESSOR X(� 5 OTNER <br /> �ORTRu 3T LANDS ICAL 000008107 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS: <br /> YS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Giammona Joe (209)368-8815 <br /> NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> GiammQnn - Joe (209)368-99 <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> JSG Trucking, Inc. Joe Gianmiona <br /> MAILING OR STREET ADDRESS ✓ bo.le R . O F O VMUAL O LOCAL.AGENCY O STATE-AGDACY <br /> 19400 N. Ilwy 99 C:2CCORPORATION O PARTNERSHIP O COLNW.AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE N WITH AREA CODE <br /> Acam o CA 0220 2 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> JSG Trucking, Inc. Joe Giammona <br /> MAILING OR STREET ADDRESS ✓ bo.lod4@ OINDMWAL OLOCAL•AGENCY E:1STATE-AGENCY19400 N. Hwy 99 K3 CORPORATION O PARTNERSHIP O COIMLY.AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE21P CODE PHONE N WITH AREA CODE <br /> 9. <br /> 9. <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-[4--]-I�t_LL� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmbYgkale O I SELF-INSURED O 2 GUARANTEE O 3INSURANCE O a SURETY BOND O 5 LETTER OFCREDIT O S EXEMPTION O 7 STATE FUND <br /> [M B STATE RIND 6 CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND S CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.q <br /> III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) JSG 'ng TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> By R Thorpe/ Contractor Owner 4/14/99 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY N <br /> m <br /> LOCATIONCOOE-OPTIONAL CENSUS TRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL +( <br /> THIS FORM MUST BE ACCOMPANIED BY AT Lb(1)OR MORE PER APPLICATION- FORM B,UNLESS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-85) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUPWORAGE TANK REGULATIONS <br />