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A , ` • t50u�cC3 <br /> STATE OF CALIFORNIA • ." °o <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR AGILITY NAA1tE NAME OF OPERATOR <br /> 09,4 <br /> ADDRESS /� A NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 11go N. P, , <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S-6 f✓ff'4� - CA D <br /> ✓BOX a CORPORATION a INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' S3ATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR RESERVATION # �1 KS AT SITE E.P.A. I.D.#(optional) <br /> a 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> / <br /> EMERGENCY CONTACT PERSON (PRIMARY) E,M GENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I HTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLE D) <br /> NAME j CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to inclicale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-( T BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [T 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 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.❑ ll.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHtDAYNEAR <br /> LOCAL AGENCY USE ONLY I D <br /> COUNTY# JURISDICTION# FACILITY It <br /> LOCATION CODE -OPTIONAL __]_CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORM TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU D STORAGE TANK REGULATIONS <br /> /L� FORM Art(6,�,95)�jA41 <br /> y>VV <br />