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Hoar <br /> STATE OF CALIFORNIA e � <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC ACILTY/SITE c"`yep""gin <br /> MARK ONLY E:] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [_] 7 PERMANENT <br /> ONE ITEM ❑ 2 INTERIM PERMIT O # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR AGILITY NAME NAMEOFOPERATOR <br /> AD ESS NEAREST CROSS STREET PARCEL#IOWIONAU <br /> CI NAME STATE ZIP CODE SCA ITE PHO E#WITH AREA CO <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#IoplimaQ <br /> 3 FARM 6 PROCESSOR 5 OTHER RESERVATION <br /> 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- ST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkal# O INDIVIDUAL LOCAL-AGENCY <br /> AGENCY <br /> CITY NAME <br /> CORPORATION = PARTNERSHIP ED <br /> COUNTY-AGENCY O FEDERFEDERALAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETE <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR-STREET ADDRESS ✓ box bindkate D INDIVIDUAL LOCAL-AGENCY <br /> (] STATEAGENCY <br /> CITU NAME CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERALAGENCY <br /> ATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxmin#kaU [—j 1 SELF-INSURED =2 GUARANTEE L=� 7 INSURANCE <br /> D 5 LETrEROFCREDIT =6 EXEMPTION L�7J A SURETYBOND <br /> 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: I.= II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# tL FACILITY <br /> LOCATION C E -OPTIONAL TRACT# OPTIONAL SUPVISOR-DIS TCODE -OPTIONAL <br /> NL <br /> THIS FORM UST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) wz <br />