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STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W.u�� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM Aa <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 4 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [::] 2 INTERIM PERMIT 4 AMENDED PERMIT Q�— 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I 4 <br /> nRA OR FACILITY NAME SAIIII COUNTY OF SAN JOAQUIN NAME OF OPERATOR <br /> JAIL HONOR FARM COUNTY OF SAN JOAQUIN <br /> ADDRESS� NEAREST ROSS STREET PARCEL#(OPTIONAL)7000 S. MICHAEL CANLIS BLVD MATHS RD <br /> l: <br /> I CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> FRENCH CAMP CA 209) 468--4648 <br /> ✓BOx LOCAL-AGENCY <br /> TOtNDICATE CORPORATION 0 INDIVIDUAL =PARTNERSHIP 0 DISTRICTS' COUNTY-AGENCY' 0STATE-AGENCY' = FEDERAL-AGENCY' <br /> 1f 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 1 GAS STATION 0 2 DISTRIBUTOR gESERVATDION OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR = 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 /> OGATA, CRAIG (209) 468-3360 HOHNSONA ALLAN (269) 468-3359 <br /> E NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME T,FIRST) PHONE s WITH AREA CODE <br /> TA CRAIG 209 957-7688 UOHNSION, AIJAN (20R4 951-1.253 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> i NAME - CARE OF ADDR SS INFORMATION <br /> COUNTY OF SAN JOAQUIN GENM SERVICES DEPARTMENT <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL [::]LOCAL-AGENCY []STATE-AGENCY <br /> r <br /> CITY <br /> WEBER `AVENUE CORPORATION 0 PARTNERSHIP ]�]COUNTY-AGENCY [� FEDERAL-AGENCY <br /> NAME STATEZIP CODE PHONE# ITH.AREA COQE <br /> STOCKTO14 CA 95202 (209 468--3358 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER SAM] SECTIONIZ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP (] COUNTY-AGENCY (] 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 /> F=ndicst, <br /> 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 0 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 /> E • <br /> i 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 TRUE AND CORRECT <br /> OWNER'S.NAME(PRINTED.&SIGNED) OWNER'S TITLE DATE MONTH/DAYIYEAR <br /> COUNTY OF SAN JOAQUIN <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m � r <br /> k LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � � FOR0003A-t7 <br /> it <br />