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w <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE rn ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR AGILITY AM� yf NAME OF OPERATOR(T el_ S 'I <br /> AD Toe ✓s Lp� NEARCST CROSS <br /> GaJ�V� PARCEL#(OPTIONNA'L) <br /> CITY NSS11 r / l/�, STATE ZIP CODE SITE PHON #WITH AREA COD <br /> ...0' 1,IC <br /> s-. 4a <br /> ✓BOX E:I CORPORATION ;4INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' E=j STATE-AGENCY' [7D FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I moral UST a e wlil"gency.wmplele the lolbwng reate of supemsordd"ion,swicin or o#Newia operates the UST <br /> TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR O 5 OTHER OR TRUSTTVATION LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NME(LAST,FIRST) /I�a ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ boxlolnGrete INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> �, ��/fp CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME / STATE ZIP CO E PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N\AMIE OF OWNER (\' ^' CARE OF ADDRESS INFORMATION <br /> MAILIN (OR STREET ADDRESS 61boxtontllcate INDIVIDUAL LOCAL-AGENCY f� STATE-AGENCY <br /> SJ ��//rF 7— [:3 CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME �� Jo r /7, ZIP COD �� PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxtDirMkate 1 SELF-INSURED O 2 GUARANTEE [:] 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT O 6 EXEMPTION [::)7 STATE FUND <br /> 9 STATE FUND&CHIEF FINANCIAL OFFICER LETTER [:19 STATE FUND&CERNFICATEOF DEPOSIT ED 10 LOCAL GOVT.MECHANISM O 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 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'STTLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR DISTRICT 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. <br /> FORMA(6-95) OWNER MUST FILE THIS FOF*H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br />