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STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> 1 l �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT e, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 07 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 16 <br /> OD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 4e,Al <br /> ADDRESS ) `/ n / NEAREST CROSS STREET ✓801taudi¢te ❑ PARTNERSHIP ❑ STATE <br /> yJ7 � 7elbj fit— Key, El IN"I CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> V / VVVVVV '1 ,v`I ��' "`���"""III ❑ INDIVIDUAL ❑ COCALAGEENCI <br /> CITY NAME Crum STATEZIP)CODE SITE PHONE A,WITH AREA CODE <br /> W," CA <br /> L 7 <br /> TYPE OF BUSINESS: ❑ ISTRIBUTO ❑ 4 PROCESSOR 7-/Bud INDIAN EPA ID a <br /> ❑ El5 OTHER RESERVATION or ❑ Not <br /> 1 GASSTATION 3 FARM <br /> TRUST(ANDS AT THHISIS 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 If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE W WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAM n CARE OF ADDRESS INFORMATION <br /> A K� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM h/ � CARE OF ADDRESS INFORMATION <br /> uS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ 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: I. T1 it. ❑ Ill. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ll I I I OXEEI I d ad <br /> CURRENT LOCAL AGENCY FACILI Y ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> Z-0/17& <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> YES NO CEJ <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Jr BY: <br /> 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. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />