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iso ^ es <br /> STATE OF CALIFORNIA „ c``� <br /> STATE WATER RESOURCES CONTROL BOARD w�� .� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �;o <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY SIE <br /> ONE ITEM O 2 INTERIM PERMIT I7 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE SV <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO AGILITY NAME NAMEOFOPERATOR <br /> ADDRESS NEA TCROSS STREET PABCELF(OFTIINAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO OR CORPORATION 0 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY (]COUNTY-AGENCY O STATE-AGENCY � FEDEiIALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(apl�anal) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:_NAM (LAST,'RST) ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRRSS/)T( , PHONN WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORM ION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b Wicale INDIVIDUAL (] LOCAL-M3ENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP D COUIITYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- UST BEC PLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box b IrAb 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTY#GENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNUMBER-Call(91 6)739-2582 if questions arise. <br /> TY(TK) HQ F4-r4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notifi 'on 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 NO (CATIONS AND BILLING: I.[::] II.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICAN TIRE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � <br /> LOCATION CODE -OP7IONAL CENSUS TRACT-OPTIONAL SUPVISOR•DISTRICT CODE -OPTIONAL <br /> 4 a 3 A 8"D 3 a�- <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 /> FORW]]AA2 �\ <br /> FORMA(e-90) <br /> a` <br />