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• oun A STATE OF CALIFORNIA is •"" `^ STATE WATER RESOURCES CONTROL BOARD -• o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 non M` COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I 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 Q I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR AGILITY AVE I NAME OF OPERATOR o /oN OGV FS,eE C�io-i ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) ISD . CITUTVN �� STATEA EMWITH REACOD ZIP CODE TEPH� 9 6�` 2� 7gy?- Zs6d BOX TOINDICATE CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL AGENCY COUNTY-AGENCY O STATE AGENCY O FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR /✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(opficini ❑ 3 FARM ❑ 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDDR�ESS• I ✓box 1a indicate f INDIVIDUAL Q LOCAI-AGENCV STATE AGENCY / �TV/�j l CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NA 1 STATE ZIP CODE / HONEIE WITREAaCOD� !!`\ J III. TANKOWNER INFORMATION.(MUST BE COMPLETED) NAMFy DIANE CARE OF ADDRESS INFORMATION MAILING OR STREET ADDREE,SSP ✓ box 011 INDIVIDUAL F-1 LOCAL AGENCY (] STATE AGENCY v/ /�A� //V✓ �� 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAYE STAT ZIP C�,011 HONE TITH ARE ODE f �y� �iJ /q ' Zd6� IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO L4 L]-L� � m V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE O 5 LETTEROFCREDIT d S RE Y BOND 6 EXEMPTION CJ 99 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.tv III,❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAVNEAR LOCAL AGENCY USE ONLY 3 17 n JURISDICTI NI # FACILITY# LOCATIONCODEOPTIONAL (CENSUS TRACTA -OPT/ONAL L iSUPVISOR-DISTRICT CODE -QIP TONAL � q7 �! 23• � 3ZD G THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 6 FOR0033A R6