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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z COMPLETE THIS FORM FOR EACH FA TY/SITE 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F-& ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME ' CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BmbMiM 0 PMiNMW 0 STATEA690 S, C / L/.on 00 INDMDU"k nm p � ❑ R� iu.AGwLr CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 7/-a c V CA `1537(c V119 TYPE OF BUSINESS: ❑2 DIAMOR ❑ d PfIOUSSOR ✓Box II INDIAN EPA ID N ❑ &S STATION 3 FARM OTHER RESERVATION w F of TANKY t E] TRUST LANDS ❑ "4000,r-7 0 3 3 AT THIS SITE f EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS NAME(UST,FIRST) PHONE N WITH AREA CODE PH NIGHTS: NAME()AST,FIRST) ENWITHAREA CODE NIGHTS: NAME(LAST,FIRST) PHONEN WITH ARFA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION an - Co . Non.¢ MAILINGwSTREET ADDRESS ✓ Io inekate 0 PARTNERSHIP 0 STATE-AGENCY (//G �� 0 ORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE I ZIP CODE PHONE N.WITH AREA CODE 0 Z21 C4 Ar. /Veb - I ivu/t-e III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION In C f /C ejf/vr1 r N V AP . MAILING w STREET ADDRESS ✓Roz to micate ElPARTNERSHIP C] STATE-AGENCY l — / 1 ?/v�Y 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY O h T f� ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE �TGL N7/�rr c C 7 L/3 V.5, L' /s j 73 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION S AGENCY B FACILITY ID R F of TANKS N SITE EE1 0 1 ° / 7 / 8 1 a 1 C) 1 o / CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY MIME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE N/A LLOCA�ONCO� CENSUSTANCTF SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 0 YES ❑ NO 5,aS 41PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATI ONL FORM A(32A8) - DATA PROCESSING COPY �