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0 i <br /> STATEOFCAUFORWA .` 'c "�o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ?ng, 's <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `����OM1+" <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADREBS NEAREST CROSS STREET PARCEL e(OPTIONAL) <br /> Ti <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA COOS <br /> 1,001 CA 9 Z t/ <br /> T 10 NDICATE O CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCALCTSENCY 0 COUNTYAGENCY• O STATE-AGENCY' O FEDERALAGENCY' <br /> N owner cl UST Is a public agency.wnplets the following:name of Supervisor of division,section,or orrice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ q SERVATDION A OF TANKS AT SITE E.P.A. I.D.a(opfatnel) <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal, <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> EET ADDRESS ✓ box bindkale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> #Q O CORPORATION (] PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY N E STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> 10/ — SAG <br /> M�1 I N OR STREET ADDRESS ✓ bob indicate 0 INDIVIDUAL � LOCAL-AGENCY O STATE-AGENCY <br /> ` =CORPORATION O PARTNERSHIP COUNIY�AGENCY = FEDERAL-AGENCY <br /> CITY N ME STATE ZIP CODE / PHONE a WITH AREA CODE <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 /> ✓ boll bindkats 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE I� SSURETY BOND <br /> O 5 LETTEROFCREDIT O 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.❑ II.❑ III.❑ <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 a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTKM# FACILITY# 1 43-A0 <br /> 0 1 Ul MED <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> Z J <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(3'93) • • �(II�I"IV e033A717 <br />