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" t <br /> �. STATE OFCAUFOfUAA <° <br /> STATE WATER RESOURCES CONTROL BOARD -• -� ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br /> ♦ Y/ <br /> O <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE ���-O"" <br /> MARK ONLY 1, NEW PERMIT 3 RENEWAL PERMIT CZ 5 CHANCE OF INFORMATION Q 7 PERMANENTLY SITE <br /> ONE REM _�] 2 INTERIM PERMIT Q A AMENDED PERMIT g TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> MOOR ,� ,.�. <br /> ADDRESS NEAREST CROSS STREET PARCEL/(OPTIONAL) <br /> CITY NAME STATE ZIP CODE D SPHON OWl AREACODE <br /> ✓ BOX l2o"1, �315— <br /> TO INOiCATE <br /> — <br /> TOINOICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL AGENCY Q COUNTY AGENCY Q STATE-pGENCy <br /> DISTRICTS Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS Q I GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. L 0.s tmimaq <br /> RESERVATION <br /> Q 3 FARM I—'i 6 PROCESSOR Q 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) <br /> WITH AREA r=g <br /> NIGHTS: NAME(LAST,FIR T) PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> u <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> - <br /> MAIL.NGORSTREETADDRESS II ✓ ' <br /> Q INDIVIDUAL LOCAL-AGENCY STATEAGENCY <br /> O nPOON <br /> Q PARTNERSHIP Q COUNTYAGENCY Q FEOERALAGENCY <br /> CITY NAME ST TE� ZIP CODE / PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) C� V <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SGt-.we as _ <br /> MAIUNG OR STREET ADDRESS ✓ Om p YIOCaI• <br /> IQ IIgNxNlµ LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEOVAAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4141-1 Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ lw bvvAGY 0 1 SELF-INSURED Q 2 GUARANTEE Q O INSURANCE Q A SINETY SONO <br /> Q s LETTER OF CREDIT Q 9 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 ch <br /> CHECK ONE Box INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D II.GLr ILL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 9 JURISDICTK)N• FACILITY 9 <br /> N71 o <br /> LOCATION COOS -OPTIONAL CENSUS r T IDOPTIGNp( (SU1PVIzSOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOn99UA-5 <br /> I <br /> __ r <br />