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ul\ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD3FORM 'A': UNDERGROUND STORAGE TANK PROGRAMSITE �ACILITY/SITE, INFORMATION and/or PE"[TAPPLICATIONCOMPLETE THIS FORM FOR EACH F ITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PER 5 CHANGE OF INFORMATION ❑7 PERMANE TLYCLOSE SITE fVQ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE r <br /> l7J <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACIUTY/SITE NAME' CARE OF ADDRESS INFORMATION <br /> lee q/r <br /> Alrcl <br /> ADDRESS ENEAAPEST CR OSS STREET ✓BmbnE[ale ❑ PARTNEABIIP ❑ STATEAGDO <br /> ❑ COR'ORATION ❑ LOX A00 ❑ FEDERAL-AGENLY <br /> Oc✓CI'S ❑ INDIVIDUAL ❑ CWTf-AGENC/ <br /> CITY NAME ZIP CODE SITE PHONE N.WITH AREA CODE <br /> yr�Gr>>cc a— A -20 9- '-s--38-63 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N N of TANKS <br /> ❑ 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUSTYATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �',/ Sc keC'�_ Zv9-/ra 3--39 <br /> s 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME `` CARE OF ADDRESS INFORMATION <br /> SC`Lei rL- <br /> MAILINGorSTREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATES �a ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: . L ❑ it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPUCANTS NAME IPRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 0 a 3 S cU O = <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAC2 3T N SUPERVISOR--DISTRICT CODE BUSINESS PUN FILED 71;M <br /> CHECKN PEI AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTNG ❑ <br /> THIS FORM MUST BE <br /> EE AqCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. - / <br /> ORM A(3-2-81k ` <br /> J`n`tT✓A1 � � DATA PROCESSING COPY % (T 1 <br />