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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <n _ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE IA ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IR15 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AGILITY NAME NAM FOPERATOR <br /> �1e�Airon ajlon 4 01452, t7ll - lJ, Parks <br /> ADDRESS NEAR ST CROSS STREET PARCEL#(OPTIONAL) <br /> 3 4 E. CL In 4s+ R w y 99 <br /> CITY NAM STATE LP CODE SITE PHONE#WITH AREA CODE <br /> t o ca 9 <br /> ✓BOX Q CORPORATION 0 INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> tl ovmerd UST M a Wbee agemy,complete Ca blbwnQ nems d slpervisord CNision,sedbn ord9ra xiiidl oparetes be UST <br /> TYPE OF BUSINESS T GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O & PROCESSOR 0 5 OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: PME(LAST,FIRTT) PHONE#WITH AREA CODE AVS: NAME(LA ,FIRST) ,1 PHONE#WITH AREA CODE <br /> Y Y L Zcq-5 - _I O; <br /> e✓!nn iCtKtnua> S60_433: NAME(LAS IRST) PHONE N WITH AREA CODE IGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> PAaIC �t+IL- 2oq-5��-809$ tvr Emcr Gnc 600-,231-0623 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NACARE OF ADDRESS INFORMATION <br /> bWWend 01_in Sch "C,( Tru <br /> MAILING OR STREESTREETAORESS ✓ box to r6mle I� MW <br /> INDIVIDUAL DLOCAL-AGENCY OSTATE-AGENCY <br /> 1307 53 9 l�CORPORATION O PARTNERSHIP l�COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �an� 80-r1la-rg- Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA FOWNERC FADDRESS NF ATION <br /> ever ter d s Co n ff m� <br /> MAILIN OR STR ADDRESS d ,,C��✓,/box to mdise = INDIVIDUAL O LOCAL-AGENCY = STATE-AGENCY <br /> Dt crA 4 QOq TSCORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> PHOcITYNhy1� /]n m (�— SIJ '45 583 51FO W�@Q-_9 A <br /> IV.BOARD OF,9EQQ14UAALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-74 - 3 9 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to in kale l SELF-INSURED O 2 GUARANTEE O 3INSURANCE 0 4 SURETY BOND 5 LETTEROFCREDTr O 9 EXEMPTION =T STATE FUND <br /> 0 9 STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSR O 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: I.❑ 11.❑ III.S <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S Nr(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> (?,k1 t e1 M K 4 m I Dnk a 9 9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 314 <br /> NT F30�v_] 124 1 5 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATL (1)OR MORE PERMIT APPLICATION- FORM B,UNLESSIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(695) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNOERGROU _1 ORAGE TANK REGULATIONS <br />