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9 0 <br /> STATE WATE OFCALIFORNIA <br /> R TOUR 3 CONTROL BOARD <br /> ^e60V; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISTTE } <br /> MARK ONLY ❑ 1 NEW PERMIT • �'' o� <br /> ONE REM ❑ 3 RENEWAL PERMIT °�4ranw^ <br /> ❑ 2 INTERIM PERMITS CHANGE OF INFORMATION <br /> I. FACILITY/SI <br /> ❑ A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> T PERMANENTLY CLOSED SI <br /> TE INFORMATION&ADDRESS•(MUST SEC DBA0 ACILITYNAME c:;I.— <br /> (� <br /> ADDRESS �+ NAMEOFOPERATOR <br /> CITY NAME ^ ,. /1j tl NEAgE3 CgOSg STREET <br /> crP Ro(oWpNAq <br /> V,BOX , V• v STATE ZIP CODE <br /> TO INDICATE Q CoRPORATIONCA d SITE PHONES WI q <br /> 'If owner of UST Is a public O INDIVIDUAL ED PARTNERSHIP <br /> ✓�qn Agency.oomPMle the following:name of S CLRTR $LOCAL-AG6NCY Q COUNTY-AGENCY' <br /> TYPE OF BUSINESS ❑ A GAS STATION uPervkor M dNkbn,eeclbn,or Wlim whkh oPwaiw IM UST O STATEAGI <br /> ❑ 3 FARM ❑ 2 DISTRIBUTOR O FEDEML-AGENCY- <br /> ❑ A PROCESSOq ❑ ✓ IF INDIAN NOF TANKS AT SITE E.P. <br /> O <br /> EMERGENCY CONTACT q, IDN(QNknap <br /> NES <br /> DAYS: NAME(LAST,FIRST) <br /> 5 OTHER q TRUSTVLANDg PERSON (PRIMARY) <br /> P E N W TH AREA CODEEMERGENCY CONTACT PERSON (SECONDARY . <br /> 0 *43 DAYS: NAME(LAST,FIRST) ) optional <br /> NIGHTS:NA (LAST FI T) '� <br /> I C PHONE N IT..AgEA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER IN FORMAT! PHONE Al WITH AREA CODE <br /> NAME ON- MUST BE COMPLETED <br /> MAILING OR STREET SCARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> ✓boi blMkaq <br /> CITY NAME INDIVIDUALf3 CORPORATION 0 LOCAL-AGENCY CD <br /> PARTNERSHIP �COU AGENCY FEDERAL-AGENCY GENCY <br /> STATE _ ZIP COPE Q FEDEgAL-AGENCY <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) PHO NENWITHAREACODE <br /> NAME OF OWNER <br /> MAILING OR STRIFE /y ��� � ) <br /> ��/I'lA(� C ' CARE OF ADDRESS INFORMATION <br /> T ADDRESS <br /> CITY NAME <br /> T ✓box bWkay ED INDIVIDUAL <br /> CORPogAR0 LOCAL AGENCY Ell <br /> PARTNERSHIP O COUNTY-AGENCY O FEDSTAERAL-AGENCY STAGENCY <br /> TE ZIP CODE �FEOERgLAGENCY <br /> IV.BOARD OF EpUALIZATION UST STORAGE FEE ACCOUNT NUMBER• aHONE N WITH AREA CODE <br /> Ty(TK) HO 4 4- _ Q a Call(9I6)322.9669 if quest ons arise. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE <br /> ✓boAbi�gN DISFLF INSURED COMPLETED) IDENTIFY THE METHODS) USED <br /> S IETTEROFCREOR 2 GUARANTEE <br /> 0 q EXEMPTION []3 INSURANCE D A SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thea k owner unless box I or II is checked. <br /> CHECK ONE BOX INDICASe <br /> TWG WHICH ABOVE ADDRESS S <br /> HOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORMHgSBEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEBEST OF <br /> ILO l.ElOwNEgB NAME(PRINTED a sIGNED) MYKNIl <br /> OWLEpT,E,IS TRUE AND CORRECT <br /> OWNER'S TITLE <br /> LOCAL AGENCY USE ONLY DATE MONTH DAYNEAR <br /> COUNTY R —yam.T1 <br /> JURISIC ICTIONa <br /> FACILITY <br /> 305 I° <br /> LOCATION CODE-OpTKVWU�LLI <br /> CENSUS TRACT e -OPTgN1AL <br /> d3 A BUPVAROR.DISTRICT -OPTIONAL <br /> n <br /> nns PDaAI 7aE ACCDMPAMEDDYAT LEAST II)DR MD)IE PBW App I TON FORM BU <br /> NLESS FORMA("3) O1Y+'TER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND 9 ORALE TANK RESILE INFORMATION ONLY, <br />