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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD •�® p <br /> UNDERGROUND STORAGE TANKoo <br /> KPERRMITAAPr PLICATION -FORMA . • i :.n <br /> COMPLETE THIS <br /> R EACH <br /> ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE E <br /> MARK ONLY ❑ d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> ONE fTEM ❑ 2 INTERIM PERMIT <br /> I. FACILITY/SITE INFORMATION a ADDRESS-(MUST BE COMPLETED)AOF OPERATOR <br /> DBA OR FACILITY NAME - PAi10ELr10PTDNW <br /> NEAREST CROSS STREET <br /> ADDRESS _ <br /> ZIP CODE SITE PHONE a WITH AREA CODE <br /> STATE <br /> CITY NAME CA 0 <br /> CMMAGENCY' Q STATE-AGENCY' Q FEDERAL'AGENCY' <br /> INDIVIDUAL Q PARTNERSHIP DISTRICTS Q CQ - <br /> ✓90% CORPORATION Q dSTAICTS <br /> TO INDICATE lams d swe d dwio.ssaron a drm w 0 WMalas filo UST <br /> USTB a pW9s a9@r1Y Wn W'Me bW IF INDIAN It OF KS AT SITE EP.A. I.D.a(C060-1) <br /> RESERVATION <br /> TYPEOF BUSINESS I� 1 GASSTATION ❑ 2 DISTRIBUTOR O 6 OTM� OR TRUST UNOB <br /> ❑ O FARM ❑ 6 PROCESSOR <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAVS NAME tLAST.RRSTt PHONE A PATH AREA CODE <br /> PHONE a WITH 'Co. <br /> A CODE — ,? 9 <br /> DAYS: NAME(LAST.FIRST) <br /> ^ _ I 1^ ,FIRST) PHONE a WITH AREA CODE <br /> PHONE a WITH AREA CODE NIGHTS: NAME( — —�( q <br /> NIGHTS: N (LAST,FIRST) <br /> G+It. PROPERTY OWNER INFORMATION.(MUST BE COMPLETED) CAPE OF ADDRESS INFORMATION <br /> tA 2P2 ✓ anM n6mla Q NDMWAL Q LOCAL-AGENCY STATE-AGENCY <br /> ADDRESS CORPORATION Q PARTNERSHIP Q COUNN•AGFNCY Q PmEPAL'�' Y <br /> ISTATELP CODEPHONE I WITTH MEA CODE <br /> `/y 942>3Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CME OF ADDRESS INFORMATION <br /> NAME OF OWNER /2 C <br /> ✓ =W ndrale �PDIMOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS Q CORPORATION Q PARTNERSHIP Q COIAIfY-/GBICY Q F®ERAL-AGENCY <br /> STATE LIP CODE PH�OTNE t......MEpA CODE <br /> CITY NAME �--A �A 5 c...LfD L�� / •L - <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ 4 4- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> 2 GUARANTEE Q]INSURANCE Q I WSETYBOND Q S LETTER OF CREDIT 0 6 MMPTM 0 7 STATEFUND <br /> SFIF-NSURED Q =1 .. rv-e !`nvi uFfNANISN Q 99 OTHER _ <br /> ✓oo ro dm <br /> Q B STATE FUND6CHIEF F9lN1CYA.OFFICER LETTER Q 9 STATE Fi1ND 6CERTIFlG t OF DEPOSIT <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 /> I.❑ K.� m�] <br /> THIS FORM HAS BEEN OMPLETEDU DERP TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PflIN ,d.:ill' TANK OWNERS TITLE <br /> DATE MONTHWQAYNrAR <br /> LOCAL AGENCY E ONLY <br /> JURISDICTION k FACILITY 0 <br /> COUNTY k <br /> m ( <br /> LOCATION CODE -OPTIONAL CENSUS TFUCT a -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOVITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO D STORAGE TANK REGULATIONS ` <br /> FORM AI6-95) � <br /> � I�al <br />