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STATE OFCALIFLO <br /> NNW r STATE WATER RESOURCES CONTROL BOARD �IvS ,-. . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATAU <br /> ff <br /> MAR 12 1993 <br /> "if <br /> COMPLETE THIS FORM FOR EACH 5Y/SITE UIVIRC44,44141. <br /> MARK ONLY F__] 1 NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMAT LOSED TE <br /> ONE ITEM 2 INTERIM PERMIT �el AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) WOOF <br /> DBA AGILITY N /� J NA4WF OPERATO ' <br /> ADDRESS C/J NEA T OSSSTREET PARCEL#(OPrIONAL) <br /> 71199 <br /> CI STATE ZIP CO SITE PHONE XQVITH AREA C DE <br /> CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION a 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION ? <br /> Q 3 FARM Q 4 PROCESSOR a 5 OTHER OR TRUST LANDS V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECOND t <br /> RY)-optional <br /> DAYS AME(LAST,FIRST) PHONE#WITH AREA CODE D NAME( IRST) j <br /> NIGHT " NA AST, IRST) PHONE#WITH AREA CODE NI S: E If WITH AREA <br /> Gc OLS <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM OF ADDRESS INFORM <br /> �7, <br /> R STREET AD SS / ✓ bo indicate Q INDIVIDUAL Q LOCAL-AGENCY TATE-AGE <br /> 0 . <br /> (� 0 3� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY ME STr ZIP CODEPHONE#WITH AREA CODE <br /> 9Q'74) '03 <br /> 03 .3/0 -sem 7-.2_,C17 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NANIE-PF OWNER C OF ADDRESS INFORM <br /> M R TRE�5Z / I/ boz gate Q INDIVIDUAL Q LOCAL-AGENCY QST AGE Y <br /> C3 ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN ME Sa— ZIP �Q� / PHONE�U#KWITH 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 -I 06D 0i ��] <br /> V. PETROLEUM UST FINANCIAL,RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Fbw to indicate SELF-INSURED =2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: <br /> THIS FORM HAS BEEN COMPLE DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP NTS NA (PRINTF &SIG TU ) APP ANTS TI �_ -�Q DATE MONTH/DAY/YEAR <br /> �� �L -r7 <br /> LOC AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 14R(c) S / 7 <br /> mI I It 55 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SU�VISQR-QISTRICT CODE -OPTIONAL <br /> (74;1 14 <br /> THIS FORM MUST BE ACCOM ANIED BY AT LEAST(1)OR MORE PERMIT APPLICATIONS- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />