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ac6pVp es c �. <br /> .uu+. <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °�i rpRN <br /> MARK ONLY F-1 t NEW PERMIT 0 3 RENEWAL PERMIT s+ -_5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITY NAME 5M COUNTY OF SAN JOAQUIN NAME OF OPERATOR <br /> JAIL HONOR FARM COUNTY OF SAN JOAQUIN <br /> ADDRESS NEAREST CROSS STREET PARCEL*(OPTIONAL) <br /> f 7000 S. MICHAEL CANLIS BLVD MATHEWS RD <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> FRENCH CAMP CA 209) 468-4648 <br /> v BOX <br /> TOINDICATE CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> DISTRICTS' <br /> t If 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 t GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION y <br /> 3 FARM 4 PROCESSOR 0 6 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, CRA — 468-3358 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> jCGATA, CRAIG (209) 957-7688 JOHNSON, ALLAN (209) 951-1253 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> NAM <br /> OF SAN JOAQUIN GENERAL SERVICES DEPARTMENT <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 'STATE-AGENCY <br /> 222 E WEBER AVENUE CORPORATION = PARTNERSHIP $]COUNTY-AGENCY FEDERAL-AGENCY <br /> OM&TON sTCIA ZI9caD�02 �6 4�vITHjgE�-3358 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) U 1 <br /> M NAME OF OWNER SAME AS SECTION II CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> I CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> i CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> i <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE [=1 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 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.a it.[�4 III.D <br /> I <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 8 SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> COUNTY OF SAN JOAQUIN <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mFTTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODf='. <br /> ( C <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 /> FORM A(3193) . FORpp;{3A.R7 <br />