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14W qwr <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED SITE <br /> ONE ITEM � 2 INTERIM PERMIT O < AMENDED PERMIT � 8 TEMPORARY SITE CLOSUflE <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA AGILITY NAME NAME OF OPE TOR <br /> ev�on S4 a- fion �k 918 e4 <br /> ADDREBS 7 NEAREST CROSS STREET PARCELX(OPTIONAL) <br /> W, t os m' c Ave. <br /> CITU NAME STATE ZIP CODE SITE PHONE X WITH AREA CODE <br /> Mand- cA 9 - 92. <br /> ✓BOX O CORPORATION (] INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGDICY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'emsnerof USTIe 5,e,kag9r, mMWWthelnlbwing.ram ofst"Mwrd ONisim,sectionmolf"e &operates the UST <br /> TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.X IOPllonaq <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE VS: NAME( T,FIRST) PHONE X WITH AREA CODE <br /> tAI >J Zo9- 92- e,ve-, i ln� nancc 800 33-3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> A JIM n)A -'95 1.2-31 Ueqf&n &rIeWrXXn4rM4hjA 0o a3/-O6 Z 3 <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> N CARE OF ADDRESS INFORMATION <br /> �E{'IP,vron P�oduc.�s rn art <br /> MAII GOR STREET ADDRESS O ✓ Asa^ 1B � INDMDUAL O LOCAL-AGENCY � STATE- <br /> AGENCY <br /> NCORPORATION � PARTNERSHIP COUNTY-AGENCY ID FEDERAL-AGENCY <br /> CITY ME ST E ZIP CODE PHONE X WITH AREA CODE <br /> 2T) m �A 45$3 510-84Z-9500 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OF OWNERFADDRES IN MATZO <br /> MGOR STR ETADDREG ✓ bommisle INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> AIO-- O D (CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAUAGENCY <br /> CIN NAME STATE ZIP�ODE �� PH'NE#7 <br /> AREA CODEn <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. 9 aL+ <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓SrnMi�rale 1 SELF-WSURED O 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND Q 5 LETrEROFCRMfT =a EXEMPTION O T STATE RIND <br /> 8 STATE FUND B CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND 6 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 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.ED II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> TANKOWNER'SME(PRINTED&SIGNATURE TANK OWNER'S TITLE DATE MONTHIDAWYEAR <br /> R � cL MIC ./�asf. urn i f Drat- a-/5 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X FACILITY X 3�J <br /> 511 ® 191311 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT X -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT Ll (1)OR MORE PERMIT APPLICATION- FORM B,UNLESS- IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM*"THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIROCTORAGE TANK REGULATIONS J-101 <br /> ill i <br /> FORM q(EBS) %Y <br />