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STATE OF CALIFORNIV WATER RESOURCES CONTROROARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u �o z SITE Z FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE "'IFOR " MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 21 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) W FACILITY/SITENAME CARE OF ADDRESS INFORMATION C ) r� evson ( 'lAI v i c) ADDRESS NEAREST CROSS STREET ✓ft I.i .Nr 0 PARTNERSHIP 0 STATE- AGENCY 13 00 IeoivlorunoN O coUUNIYAoENc Cl EEUUL Gaa CITY NAME STATE CA ZIP-CO�33� SITE PHONE N,WITH AREA CODE ` 1I,n 4ec-6— TYPE OF BUSINESS: F–] 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz,(INDIAN EPA ID N (`"))�( 1f�, RESERVATION or M of TANK'e / ❑ IGAS STATION ❑3FARM ❑'S-OTHER TRUST LANDS ❑ �� AT THISBITE O� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) � PHONE 4 WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE 0 WITH AREA CODE 1 ` NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMEpIvin It PC PnC-o( 5cn CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY Y�• 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY y� F_ I Cl.� ) 1 c� 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME ^ a'^ 1 l c STATE,C� ZIP � PHONE I III. TANKC OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ^^ ^^ CARE OF ADDRESS INFORMATION �lirvk__V, MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE. IV. LEGAL NOTIFICATION AND BILLING ADDRESS -CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. w I. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY It JURISDICTION M AGENCY# FACILITY ID M It of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE Gln cR90 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C09E CENSUSTRA,CTI SUPERVISOR-7TRICT(CODE BUSINESS PLAN FILED NO ❑ i� I�D CHECKF PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-BB) ,/ DATA PROCESSING COPY •