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wP Pt°0y..: CpA <br />STATE OF CALIFORNIA <br />f� STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANKPERMIT PPLICATION - FORMA40 <br />• C�tIFOP Nor <br />COMPLETE THIS FORM FOR EA FACILRYISITE <br />MARK ONLY 0 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 7 x 1 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />DAYS: NAME (LAST, FIRST) <br />PHON <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NAME OF OP ATOR <br />SAN JOA011IN r0 PARKING <br />i; <br />CITY NAME <br />STATE <br />ADDRESS <br />PHONE # WITH AREA CODE <br />L� b <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />121 S. SAN JOAQUIN <br />ST. <br />MARKET <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />STOCKTON <br />CA <br />95202 <br />✓ Box <br />TO INDICATE CORPORATION <br />INDIVIDUAL 0 PARTNERSHIP <br />LOCAL -AGENCY II COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORO <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />0 3 FARM <br />4 PROCESSOR a 5 OTHER <br />OR TRUST LANDS <br />ONE <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />PAUL GARCIA <br />DAYS: NAME (LAST, FIRST) <br />PHON <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II_ PROPFRTY OWNFR INFORMATION - (MUST RE COMPLETED) <br />NAME <br />COUNTY OF SAN JOAQUIN <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box bindicate INDIVIDUAL 0 LOCAL -AGENCY E::] STATE -AGENCY <br />121 S. SAN JOAQUIN STIA t <br />CORPORATION PARTNERSHIP Q COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />L� b <br />_' <br />^5202 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />COUNTY OF! SAN JOAQUIN <br />CARE OF ADDRESS INFORMATION <br />�u1/ LaNGQpSTREFTApDREBSAQUIN ST. <br />11 LL l `� �5[A�I1VV <br />✓ box blydcate = INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />CORPORATION = PARTNERSHIP i COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />STOCKTON <br />CA. <br />95204 <br />IV. BOAR UALIZATION UST STORAG-rFSkACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) kQ 4 4 - <br />V. PETROLEUM U P - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />F <br />box bindicate 1 SELF-INSURED (� 2 GUARANTEE 0 3INSURANCE 4 SURETY BOND <br />D 5 LETTER OF CREDIT Q 6 EXEMPTION 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. K it. D III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY, OF PERJ(.IRY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br />JAMES (tex) STOKLEY .PRES. 12-22-92 <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />� � a <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />0/ a '30 <br />THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B. UNLESS THIS IS b CHANGE OF SfIt INFORMATION ONLY. <br />FORM A (5-91)FOR0033A-5 <br />10 0 1�� <br />