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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 e,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A se _ ,, a COMPLETE THIS FORM FOR EACH FACILITYISITE m MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR AGILITY AME p NAME OF OPERATOR AD RESS / i NEAREST CROSS STT . PARCELt(OPTIONAL) CITY NT, W STATED ZIP CODE SITE PHONE#WITH AREA COO _(1 CA O ✓ BOX CD CORPORATIONI INDNIOUAL O PARTNERSHIP O LOCAL-AGENCY El COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS *I ownerof UST's a publlo agwq,m fete the following name ol supeMsor ol divism,Wixl aro#ke xfiich operates the UST TYPE OF BUSINESS1"dI 1 GAS STATION Q 2 DISTRIBUTOR ❑ REV IF INDIANATION #OF TANKS ATS ITE E.P.A. I.D.p(ppfionel) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE A so NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMEN CARE OF ADDRESS INFORMATION I?LtCA L �✓//.1.E /4j e MAILING OR STREETADDRESS ✓ bovto mdrale INDIVIDUAL � LOCAL-AGENCY O STATE-AGENCY P- �Lh CORPORATION M PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME n�CJ �, ll� CTA ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C N EOFjWNERecie Y/N CARE OF ADDRESS INFORMATION MAIL?ORSTREET ADDRESS ✓ baetondirate INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY /�/ -� G�Y e7 Q CORPORATION PARTNERSHIP COUNTY-AGENCY EDFEDERAL CITYNAME `v �1�" Sk1T ZIP CODE PHONE#WITH AREA CODE sftN Jor L, 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 METHOD(S) USED ✓wto lMeate 1� 1 =CHIEF 2 GUARANTEE 0 3INSURANCE O 4 SURETYBOND O 5 LETTEROFCREDIT O 6 EXEMPTION O T STATE FUND e STATE Fl1NDd CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM BB OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ it. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It F7 aaEgml LOCATION CODE-OPTIONAL CENSUS TRACT# -OP77ONAL SUPVISDR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, OWNER MUST FILE THIS F010"THE LOCAL AGENCY IMPLEMENTING THE UNDERGR•STORAGE TANK REGULATIONS FORMA(6.95)