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tb Vp C <br /> STATE OF CALIFORNIA �r <br /> STATE WATER RESOURCES CONTROL BOARD W m 1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT0 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AGILITY NAME �sj) / NAM OPERATOR ; <br /> ADD Ste^ NEAREST CRO STREET PARCEL#(OPTIONAL) <br /> ffj 17 <br /> /1r1. �, <br /> CITY NAME,.? STATE ZIP WDE SITE PHONE#WITH AREA CODE <br /> D��Klm CA <br /> I/ BOX <br /> TO INDICTE CORPORATION INDIVIDUAL I]PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION = 2 DISTRI13UTOR0 RESEIF R INDIAN #OF T S AT SITE E.P.A. 1.D.#(optional) <br /> ON <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. OPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION L <br /> NOCA L, <br /> MAIL OR STREE DRE S ✓ box b Indicate INDIVIDUAL LOCAL-AGE CY 0 STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ST ZIP ODE ��� PHONE#WITH AREA CODE <br /> C�A1 TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> r y/ NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �1 MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (�CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ4 -- - of (� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate 0 1 SELF-INSURED (]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> E=1 5 LETTEROFCREDIT 6 EXEMPTION (]99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ Il.V III.7 <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(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39 1 Oz V?)TF1 ITE -too-q <br /> LOCATION C D -OPTIONAL CENSUS TRACT# -t7P f0 L SUPVISOR-DISTRICT CODE - NAL <br /> f <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(3/93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA'I <br /> _ l7 �, /fOR0033A R7 <br />