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jr-T-Try TP,-- . -r.- .�� ..,,--.� r-....fi •�i n -�i', .a <br /> STATE OFCAUFOM".- <br /> -STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> COMPLETE THIS FOAM FOR EACH FACILITYMTE `'<<•a�*'' <br /> I: <br /> MARK ONLY D' 1 NEW P 5 <br /> ERMrr 3-RENEWAL PERMIT �` "-CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM. O 2 INTERIM PERMIT Q 4 AMENDED PERMIT ' 6 TEMPORARY SITE CLOSURE <br /> E <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST.BE COMPLETED}' <br /> DBA OR AC ITY NAME NAME OF OPERATOR <br /> ADDRESS NEARESTCROSSSTREET - PARCELe(OPrIONAy <br /> Zvo <br /> CITY NAME_ STATE <br /> j'7JP COOS SITE PHONE s WITH AREA CODE <br /> kr-,4 " CA <br /> T NDICATE O CORPORATION p INDIVIDUAL p PARTNERSHIP © LOCAL-AGENCY ©COUNTY•AGENCY- p STATE•AGENCY- p FMERAL.AGENCY' <br /> If owner d UST Is a publicency.aonplete the[ DISTRICTS•,{ <br /> a9 oCa+nAng:name of Superv�or d division.section,or otlics which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTAIEUTOR p' ✓ IF INDIAN is OF TANKS AT SITE E.P.A. L D.s{cplranaq <br /> Q 3 FARM p 4 PROCESSOR OTHER RESERVATION <br /> ORITRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NA E(LAST, IR ST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE.i WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST] PRONEO WITH AREA CODE. NkaHT3:[(AME(LMT.FIRST) PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFOR TION- UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box top INDIVIDUAL p LOCAL-AGENCY' p STATE-AGENCY <br /> ©CORPORATION.. p PARTNERSIdP p COUNTYACO CY p FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WTTH'AREA CODE <br /> 111..TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NA4E O OWNER CARE OF ADDRESS INFORMATION <br /> ��. T r If <br /> MAILINGRSTREETADD S' Z barlp�ats <br /> p INDIVIDUAL ©LOCAL-AGENCY © STATE-AGENCY <br /> f <br /> Z /' �[ ✓� p CORPORATION I] PARTNERSHIP p=XTY.AGEICY [] FEDEAAL•AGENCY <br /> CITY NA STATE ZIP CODEPHONE s AREA CODE <br /> ZL? -7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cal!(916)322-9659 i1 questions arise. <br /> TY(TK) NO F474-1-1 <br /> V.. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS} USED <br /> ✓ boa bindkaos ©1 SELF-INSURED _ p 2 GUARANTEE p]I#SURANM _ . p 4 SURErY BOND <br /> p 5 LErTfiROFCREDIT p a E%EMPnON [] 99 OTHER ' <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or-I1 is checked. <br /> F- <br /> ECK <br /> ONE.BOX INDICATING WFIICH ABOVE ADDRESS-SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I:0 IL IIL Q <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C&nECr <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'STTTLE DATE MONTIkIDAYIYEAR <br /> 4t <br /> LOCAL AGENCY'USE ONLY <br /> COUNTY* JURISDICTION# FACILITY i <br /> LOCATIO CODE -01PT1pN4L CENSUS TRACT s -OPTIONAL SUPVISOrt•DISTRICT CODE-OP'TJbIWt <br /> Q . ? z;,, <br /> THIS FORM MUST BE ACCOMPAMF-D BY AT LEAST(1)OR MORE PERNFr APPLICATION-I FORM B,UNLESS THIS IS A CHANGE OF SM W-ORUTION ONLY., <br /> OWNER MUST FILE THIS FORMWE LOCAL AGENCY IMPLEIEM'ING THE UNDERGROU €TANK REMOTIONS <br /> FORM A(31931 <br /> w FCROCIL <br />