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STATE OF vALI IORNN? WATER RESOURCES CONTROBOARD s zE e <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^ArronN�" <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> W <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> C-R-- V 0 C. <br /> ADDRESSNEAREST CROSS STRE T 3%IN Mule 0 PARTNERSHIP STATEAGENCI <br /> Pv/ 0 A_L8C_a� (2-Pn� C h T ❑ coRPORanoN ElLo Ac Rc B FE6 —RALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTFAGENU <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 9 's <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box 0INDIAN EPA ID N <br /> I GAS STATION 3 FARMTHEfl RESERVATION or ❑ <br /> If of TANK's <br /> TRUST LANDS n �. AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE H WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Iointlicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. II. III. <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION If AGENCY N FACILITY ID Al #o1 TANKS at SITE <br /> Id ©1 ( 121 ( 111 16610101 <br /> CURRENT LOCAL AGENCY FACILITY ID M Sc k V O 0 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT N CODE CENSUS TRACT# SUPERVISOR-�TgICT CODE BUSINESS PLAN FILED DATE FILED <br /> II YES E] NOEl U ., A <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> \ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OHM A(3-2-88) C J <br /> DATA PROCESSING COPY J I <br />