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144T•- <br /> STATEOFCAL1FOiiNIA <br /> STATE WATER RESOURCES CONTROL BOARD a` $ <br /> } l� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �.t,fgR,,• <br /> MARK ONLY1 NEW PERMIT S RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT E__1 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TYAAM NAMEPERA OR <br /> o d�N <br /> ADDR S <br /> NEA;W CAOSSSTREET , PARCEL#(OPTIONAL) <br /> CITY N STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> G � C/� <br /> ✓ BOX <br /> TOINDICATE 0 CORPORATION INDIVIDUAL =1 PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY STATE•AGENCYFEDERAL-AGENCY' <br /> If owner of UST Is a public agency,complete the following:name of Superwtsor of divlskm,section.or office whIch <br /> operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(gol'ronal) <br /> S FARM 0 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,F 5T) PHONE#WITH AREA CODE DAYS; NAME(LAST,FIRST) PHONE#WiTH AREA CODE <br /> NIGHTS: NAME ILAST,FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,F#RST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INEORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ESTATE <br /> box ta#rdicals 0 INDIVIDUAL LOCAL-AGENCY � STATE-AGENCY <br /> CORPORATION [] PARTNERSHIP E== UNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ZIP CODE P NE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate I] INDIVIDUAL LOCAL-AGENCYTODE <br /> ENCY <br /> []CORPORATION <br /> O PARTNERSHIP <br /> COUNTY -AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH A <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box k)Indicate Q I SELF-INSURED Q 2 GUARANTEE 0 5 INSURANCE <br /> 4 SURETY BOND <br /> 0 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 it is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE:ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL E III. <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEL)GE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TRUE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrrY 0 <br /> CEJ <br /> LOCATION CODE -OPTIONAL CENSUS T ACT ;OP 10NAL SUPVdSOR-DISTRICT CODE -OPTIOML <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 /> FORA A{3183) <br /> OWNER MUST FILE THIS FORM WITH THE L AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0009A-RT <br /> 0 ���r'_ *l 3 <br />