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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ""� "° <br /> oo .� os <br /> COMPLETE THIS FORM FOR EAC FACILITYISITE <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 <br /> 53 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA q R AGILITY,}NAME f [� NAME OF OPERATOR <br /> ADDRESS <br /> t})e) Jfb /� <br /> CITY NAME NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> /I C„- Diablo(L�aI <br /> �+�e / STATE ZIP CODE SITE PHONE>e WITH AREA CODE <br /> _? ��'/ 1 CA <br /> I/ BOX <br /> TO INDICATE Q CORPORATION [] INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> COUPfiYAGENCY =,gTATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 0 OF TANKS AT SITE E-P.A. L D.0(optimal) <br /> �J <br /> 0 3 FARM RESERVATION <br /> 4 PROCESSOR ❑ S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE l<WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Dox bindicate <br /> 0 IND{VIpUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME i�CORPORATION = PARTNERSHIP Q COUNTYAGENCY = FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS ✓ box Io Wicate = INDIVIDUAL <br /> �]CORPORATION © LOCAL•AGENCY �STATE-AGENCY <br /> [� PARTNERSHIP = COUNTY-AGENCY d FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COOS <br /> PHONE t+WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)739-2582 if quesgarts arise. <br /> TY(TK) HQ 7474 -L <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and bilting will be sent to the tank owner unless box I or 11 i5 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING; I.❑ ll.❑ III.❑ <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND To THEBEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTHtDAYtYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# C—� JURISOICTION# FACILITY# <br /> NAYAI- 3/ <br /> LOCATEON CODE -OPTIONAL CENSUS TRAC -OPTIONAL SUPVISpR-DISTRICT CQDE -OPTIONAL jQ� :3,z <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 /> FORM A(9-90) <br /> FOA0033A-A2 <br />