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STATE OF CALIFORNIA ` _ "o STATE WATER RESOURCES CONTROL BOARD .o� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `• rw COMPLETE THIS FORM FOR EACH ACILFYISITE MARK ONLY D 1 NEW PERMIT O S RENEWAL PERMIT Lv 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL ONE REM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FAC LITYISITE INFORMATION&ADORES -(MUST BE COMPLETED) DBA AGILITY NAME � NAME OF OP OR � / D /+/ NEAREST 6ROSSS EET PAROELa(OPTIINAL) CI NAME STATE ZIP ! ,�� SITE PHO E a W AR CODE CAIvy ✓ Box CORPORATION O INDIVIDUAL [:J PARTNERSHIP f� LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TOINdCATE DISTRICTS. •x owner of UST Is a public agency,mnplete the following:name of Supervisor of division.section,w office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR RESERVATION a OFT S AT SITE E.P.A I.D.Js tophmal) Q 3 FARM 4 PROCESSOR Q b OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ONtb NtlbA 0 INDIVIDUAL LOCAL-AGENCY f�STATE-AGENCY Q CORPORATION O PARTNERSHIP D COUNTYAGENCY O FEDERALAGENCY CITU NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bw[birdleNa INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY =CORPORATION PARTNERSHIP ED couNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓ bol binGesN O 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT Q S EXEMPTION =99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Uri es x I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.Q III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTHIDAYNFAR LOCAL AGENCY USE ONLY 56 JURI R L • FAC mu -ci LOCATION CODE -OP CENSUS TRACTS -OP 9UPV1S0R-DISTRICT 13-7-1 THIS FORM MUST BE CC MPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A C ANGE OF SITE IWORMATION OJIY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3(93) MA]