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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Y 201 a?Q <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A00, <br /> 9 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 7 PERMANENTLYCLOSED SITE�y l <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE 7 �v <br /> c <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> r)RA Oct FACILITY NAME - COUNTY OF SAN JOAQUIN NAME OF OPERATOR <br /> JAILZHONIOR FARM COUNTY OF SAN JOAQUIN <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7000 S. MICHAEL CANLIS BLVD MATHEWS RD <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> FRENCH CAMP CA 209) 468-4649 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY <br /> DISTRICTS' COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY' <br /> It owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 i GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN 1#OF TANKS 1 SITE I E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> GATA CRAIG 209 957-7688 JOHNSON, ALLAN 209 951-1253 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> COUNTY OF SAN JOAQUIN GENERAL SERVICES DEPARTMENT <br /> MAILING OR STREET ADDRESS ✓ box toindicate <br /> INDIVIDUAL = LOCAL-AGENCY (]STATE-AGENCY <br /> 222 E WEBER AVENUE CORPORATION (] PARTNERSHIP X:1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> STOCKTON CA 95202 1 (209) 468-3358 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER SAME AS SECTION II CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> (]CORPORATION Q PARTNERSHIP (]COUNTY-AGENCY 0 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 1 SELF-INSURED F__1 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETrEROFCREDIT 0 6 EXEMPTION Q 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.E:1 II.[:X III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> COUNTY OF SAN JOAQUIN <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# r' 3 507 <br /> m FTTI - <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE'7101112711ONAL 1-v -1, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE moRukTi6ioNLY. <br /> FORMA(3+93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 � � <br />