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0(0 yOUR � <br />STATE OFCAUFORNIA RECEIVE <br />6001- STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FW f 2 1993 <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE ENVIRONMENTAL HEAL <br />MARK ONLY ❑ 1 NEW PERMIT � 3 RENEWAL PERMIT F75 CHANGE OFINFORM I LOSED SITE <br />ONE ITEM 0 2 INTERIM PERMIT I ✓1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION ADDRESS - (MUST BE COMPLETED) <br />DBA O AGILITY NAM E OF OPE TOR /' . <br />1 <br />EMERGENCY <br />- • •. .. <br />s4E (L AST /F I t) PHONE # WITH AREA CODE <br />i <br />11. PROPERTY OWNERjyFOWATIOjV-_W <br />t�i r� .� ....;,r.!1:i 'I:s y► -✓.+rte '�.i o /jam....-. -.t <br />ST <br />BEET ADgIfiFSS box ID I to <br />r <br />\ OW i \ iitll4•\ 11 •1(• [' <br />PERSON• DA <br />= .•. <br />INDIVIDUAL Q LOCAL -AGENCY Q OATE-AGED' <br />PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY - <br />PHONE # WITH AREA CODE <br />.2 —Gx%i� /d -- 4407— .2— (::.-/ % <br />NA OF OWNER <br />F ADDRE S INFORMATION <br />ADSS /, t <br />EA S OSS STRE T <br />PARCEL # (OPTIONAL) <br />CITY <br />STATE]ZIP <br />CODE <br />SITE PHONE # WITHAREA CODE <br />CA <br />�ry <br />/ <br />-- per— 6-4- <br />S <br />✓ BOX <br />I/ <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 BUSINESS 1 GAS STATION a 2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # Wflonal) <br />S5CODE y <br />G/ ®oc. <br />RESERVATION <br />\ ? <br />Q 3 FARM 4 PROCESSOR ` Q 5 OTHER <br />OR TRUST LANDS <br />V <br />1 <br />EMERGENCY <br />- • •. .. <br />s4E (L AST /F I t) PHONE # WITH AREA CODE <br />i <br />11. PROPERTY OWNERjyFOWATIOjV-_W <br />t�i r� .� ....;,r.!1:i 'I:s y► -✓.+rte '�.i o /jam....-. -.t <br />ST <br />BEET ADgIfiFSS box ID I to <br />r <br />\ OW i \ iitll4•\ 11 •1(• [' <br />PERSON• DA <br />= .•. <br />INDIVIDUAL Q LOCAL -AGENCY Q OATE-AGED' <br />PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY - <br />PHONE # WITH AREA CODE <br />.2 —Gx%i� /d -- 4407— .2— (::.-/ % <br />NA OF OWNER <br />F ADDRE S INFORMATION <br />AP CANTS TITLE <br />I <br />o� <br />DATE <br />M NTT7,;�� <br />M RSTREET DRESS <br />✓box�ind' e Q INDIVIDUAL <br />Q LOCAL -AGENCY ATE -AG <br />COR ATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY E --- <br />ST <br />ZIP <br />PHONE # WITH AREA CODE <br />is <br />S5CODE y <br />G/ ®oc. <br />/ <br />Z6 <br />BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT N ER . Call (916) 323-9555 if questions arise. <br />TY ) Q - Q�'Dty <br />V. PETROLE NANCIA LITY - (MUST E COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box b indicate E�Tl SELF-INSURED Q 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: L � IL � <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />A I ANT'S E (PRINT D & SIGMA RE) <br />AP CANTS TITLE <br />I <br />o� <br />DATE <br />M NTT7,;�� <br />- <br />tP <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # <br />�K F-1-17_ <br />LOCATION CODE - OPTIDWAL I CENSUS TRACT # - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY -AT LEAST (1) ®R MORE PERMIT APPLICATION - <br />FORM A (5-91) <br />FORMATION ONLY. <br />FORD033A5 <br />