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I l <br /> oe <br /> STATE OF CALIFORNIAw WATER RESOURCES CONTROCBOARD ` ,EP'.""" "•:. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 12'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACI1:T 'E NAME T14%� S "TOYV I NiCr- CARE OF ADDRESS INFORMATION <br /> MEM_ <br /> SIBBIS <br /> ADDRESS NEAREST CROSS STREET ✓BmW xIMe 0 PARTNERSHIP 0 STATE#GENCYCo <br /> IHI 0 CORPORATION 0 LOCAL-AGENCY 0 KDEPA1�AGENCY <br /> IS rLJWRDNDUAL 0 CWNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA S CZ00 -( <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID p <br /> RESERVATION or ❑ of SITE[j2111 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS AAT TRISHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME( ST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> CS <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME p._��L CARE OF ADDRESS INFORMATION <br /> S"1 I'r l� <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. 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 E JURISDICTION N AGENCY N FACILITY ID If N of TANKS at SITE <br /> 0 C)I 1o <br /> CURRENT LOCAL-AGENCY FACILITY IO a PP VIED BY NAME PHONE a WITH AREA CODE <br /> /5? <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E PIRATION DATE <br /> LOCATION CODE CENSUS TRACCTT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �3, S-0 YES � NO ❑ <br /> CHECK#I PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESSTHIS IS A CHANGE OFSITE INFORMATION ONLY. <br /> FORM A(3-2-881 �1 <br /> I <br /> +�' DATA PROCESSING COPY './( <br />