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_. . . <br /> STATE OF CALIFOR <br /> WATER RESOURCES CONTR BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; �" o <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE()SITE <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ­4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME Y CARE OF ADDRESS INFORMATION co <br /> -�Ply Tirnt <br /> ADDRESS Or NEAREST CROSS STREET ✓Bm Wi W ❑ PARTNERSHIP ❑ STATE AGENLY <br /> ❑ MTION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> OMWAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA Sa0� o?Oy-�/6 -y <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 P5PK§kR ✓Box if INDIAN EPA ID# <br /> SE <br /> I GAS STATION ❑3 FARM OTHER TRUSTYLANDS or ❑ #oI TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> ,Tol s .� apq-yGv-YY <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lk e ✓f7/inS{sy�. <br /> MAILING or STREET ADDRESS ✓B ointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Sce C[ ❑ ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> See a/�0.�-2. <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> -Z- <br /> MAILING or STREET ADDRESSJ to indicate El PARTNERSHIP ClSTATE-AGENCYCORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 11. ❑ 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 /> COUNTYIN JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE'15 _ <br /> URRENT LOCAL AO(3NCY FACILITY to# _ APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER �7Y(CYI� c' "11•(I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ]LWION <br /> YES NOCHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT#THISFORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFOR ONL . <br /> FORMA(3-2-88) <br /> / DATA PROCESSING COPY • <br />