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yy [ <br /> STATE OF CALIFDRWA yr. •" <br /> STATE WATER RESOURCES CONTROL BOARD i g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> O Y <br /> E_MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL <br /> ONE REM O 2 INTERIM PERMIT O 4 AMENDED PERMIT -T <br /> El 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR AGILITY NAME <br /> 6 WE R <br /> NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PARCELiIOPrXWAU <br /> CITY NAME�., <br /> O 9TATE LP SITE PHONE i WITH AREA CODE <br /> ✓ BOX 6A <br /> TO INDICATE XCORPOMTION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTYAGENCY' <br /> •H omu d UST M a public agen DISTRICTS' STATE-AGENCY' 0 FFDERAL.AGENCY <br /> ry,mrrplde the following:naaw d Supervbor d dNYbn,section,w Office which operates the UST <br /> TYPE OF BUSINESS 1 Gp3 STATION Q 2 DISTRIBUTOq ✓ <br /> 6 OTHER RESERVgTIOIF INDIAN N If OF TANKS AT SITE E.P.A. I.D.i <br /> OR TRUST LANDS (eptlmy) <br /> Q 3 FARM Q 4 PROCESSOR O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•AtptlontM <br /> DAYS:NAME RAST,FIRST) PHONE i WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS:NAME(LAST,FIRST) <br /> PHONE i WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMErTX2 IV 6A)/ CARE OF ADDRESS INFORMATION <br /> MAILING Oq STREET ADDRESS /~•/ ✓bubkdCAa <br /> O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME ` O I O CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDEMLAGENCY <br /> STA ZI� DE NIXJE WITH AREA---E <br /> b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bb6c M, <br /> INDIVIDUAL 7 LOCA4AGENCY =STATE AGENCY <br /> CITY NAME D CORPORATION PARTNERSHIP 0 COUNTY AGENCY 0 FEDERALAGENCY <br /> STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO [4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hos bYMkab 0 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE <br /> 0 5 LETTEROFCRED0%OTHER <br /> T D a EXEMPTION O 1 SURETY BOND <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: ��/AI <br /> L❑ N.y l Ill.O <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(PgINTED b SIGNED) OWNER'S TITLE <br /> DATE NIONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> couNry s JURISDICTION <br /> x + <br /> E-OPTIONAL CENSUS 7RACTi -awTADnw. 9UPVISOR-DISTRICT CODE -q^ <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 /> FORMA(3q3) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> n <br /> 1!)ttu�• Deco Ce9� f�, �- �a��/ �.�O�I �I//iJ Fg7001]AAT <br />