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STATE OFCAUpDRMASTATE WATER RESOURCES CONTROL BOARD •``° ,; c <br /> I � UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> °•[v°n Nn• <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT <br /> ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAOR AGILITY AME <br /> ADDRESS <br /> S NAME OF OPERATOR <br /> a, - NEARES7CROSSSTREET PARCEL#((I IONAD <br /> CITY NAME �atD <br /> JSTATE ZIPI I E SITE PHONE#WITH AREA CODE <br /> ✓ Box CTA <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP ED LOCAL-AGENCY <br /> 'I owner of UST Is apublic agency,comPINe the following:nameof Supervkor of division,section,IS oDRICT , O COUMY-AGENCY• 0 STATE-AGENCY• E::] FEDERAL-AGENCY' <br /> TYPE OF BUSINESS OPeratee the UST <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. L D#(apt/pia// <br /> ❑ 3 FARM Q 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIR EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> TS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INF RMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORESS <br /> ✓OoxblM 0 INDIVIDUAL <br /> (] LOCAL-AGENCY O STATE-AGENCY <br /> CITU NAME �COgPORATI O PARTNEflSHIP (]COUNTYAGENCY �] FEDERAL-AGENCY <br /> STATE ZIP DE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION (MUST BECOMPLETED) <br /> NAME OF OWNER \ <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> \ ✓box birdicate 0 INDIVIDL)A 0 LOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME O cc ATION 0 11P 0 COUNTY-AGENCY (]FEDERAL-AGENCY <br /> �� STATE 21P CODE <br /> \ PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if quesp s arise. <br /> TY(TK) HQ 4 4- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST B COMPLETED)—IDENTIFY THE METHOD(S) SED <br /> ✓ <br /> box birdkale (] I SELF-INSURED 2GUARANTEE <br /> D 5 LETTER OF CRIED T O B EXEMPT ON ED 9 INSURANCE 0 4 SURETY BOND <br /> O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I\ON is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS 1.0 <br /> TR❑UEAND C RRECT II E::] <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'S TRLE <br /> DATE MONTWDAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> FACILRY# \� <br /> tA� <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OpTI <br /> C� SUPVISOR-DISTRICTQODE.JK)NgL \ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS CI$O%A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(y93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK OF SITE TIONS INFO <br /> 64 <br /> .R, <br />