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t <br /> STATi OR CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> Okla <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0,V TY NAME (F3NAME of PERATOR <br /> ,V <br /> I <br /> ADDS rn NEARES CRO STREET PARCEL If(OPTIONAL) <br /> CITY NAME STATE ZIPdbDE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX �✓ CORPORATION (]INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' (] FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If owner of UST is a public agen ,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER ORTRUSTVATION LANDS 3000-39 1117 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAM LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NI S: NAME( AST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPL <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET An&qFSS ✓ box b indicate L LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME [STATE71P CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INF 10 MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 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) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bIndicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 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: <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY 1 14 <br /> COUNTY# JURISDICTION# ( FACIL�ITY�# C!('1 - <br /> �5 / I ��l ! I/ 1 17 I � <br /> LOCATION CODE -OPTIONAL 7 CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) 0 <br /> 0 FOR0033A-R7 <br />