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0 <br /> STATE OF CALIFORNIA °. <br /> STATE WATER RESOURCES CONTROL BOARD spa, "'� } <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A : � '°: <br /> P ;YIr � D <br /> Crt,r�(X',') <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONIV T PERMANENTLY CLOSED SITE <br /> ONE ITEM 1:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .6 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AGILITY NAMEI� . NAMEOFOPERATOR <br /> ADDR70Y^/ .•VV//� N R^TCO SSGTRE� PARCEL#(OPIONAu <br /> � <br /> CITY NA STATE 5 ZIPKEOQ.j / SITE PHONE x WITH AREA CODE <br /> CAI/ BOX <br /> N D <br /> TOINDICATE 0 CORPORATION 0 INDIVIDUAL (] PARTNERSHIP (]LOCAL-AGENCY 0 COURrY-AGENCY STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN x OF TANI$,�A,T SITE E.P.A. I.D.x(op <br /> lianaq <br /> RESERVATION <br /> ❑ 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)r optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME LSC// ^ CARE OFA ESS <br /> J/ WLEdOAT✓I/OpL, <br /> MAILI '// REETgXS 0 INDIVIDUAL <br /> / <br /> /! LOCAL-AGENCY/ <br /> 0COUNTY-AGENCY FEDERAL GENCY <br /> ORPoRAPON D PARTNERSHIP <br /> CITY NAME STA ZIP CODF.�% PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C L <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 0 Wicat# O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 74 - <br /> 'L 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindbau O 1 SELF-INSURED 0 VIGILARANTEE 0 3 INSURANCE 0 4 SURETYBOND <br /> 5 LETTER OF CREDT EttS EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II i 4ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# "t77 4if JURISDICTION# FACILITY# <br /> SWJ' D <br /> LOCATION CODE -OPj70NAL ICENSUS.MACS0;CIE TIONML SUPVISOR-D T QCT 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. I <br /> FORM A(591) <br /> ' FOROD'wiAd <br /> a <br />