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STATE OF CALIFORNIA w o <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYJSITE <br /> MARK ONLY /] 21 <br /> NEW PERMIT F] 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT F-7 4 AMENDED PERMIT Ej] B TEMPORARY SITE CLOSURE 0 <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA MRI LITY NAM NA E—F PERATOR 3 <br /> AD S <br /> NEA E T CROSS THE T PARCEL O(OPTIO } <br /> Cl 1_�{/�(JJLJ STATE ZIP E SITE PHONE#WITH AREA CODE <br /> AICI �7 �7 <br /> f� Ci 1711 �I! <br /> TOfNDICATE D CORPORATION 0 INDIVIDUAL PARTNERSHIP F__1 DS RIC SENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN Itt OF TANKS AT SITE E.P.A. @.D.#(optional) <br /> RESERVATION <br /> a 3 FARM 4 PROCESSOR = 5 OTHER ��OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONES WIJH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE;WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CQn <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREE�ADDRESS����� <br /> xtolndicats E= INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREE <br /> CORPORATION © PARTNERSHIP 0 COUNTY•AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> // NAME OFOW� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS .f box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CIT NAM-E— s STATE ZIP CODE PHONE#WITH AREA CODE <br /> Q� CA <br /> ,g9q-s�3ro <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ ! 4 4 -1019 l _ 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> box to indicate I SELF-INSURED L 2 GUARANTEE 9 INSURANCE 4 777ROND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank 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 I1. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> r7ED 8 SIGNATURE} APPLICANT'S TITLE <br /> DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 'j • JURISDICTION# FACILITY# <br /> 9 I _ <br /> LOC ATION COD P710NAL (,ENSUS TF�A # -0 AL SUPVISO€i-DIS I ODE -OPTIONAL <br /> THIS FORM MUST HE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> rORM A(17 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FDR' <br />