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STATE OF CALIFORNIIKsow WATER RESOURCES CONTRObn,OARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> Sil FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH HCILITY/SITE "11108 ' <br /> MARK ONLY ❑ t NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMAN LY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Silvio 'I Oopm.A, <br /> ADDRESS F-N „ Da-441 e4W JNEAREST CROSS STREET PASTIME <br /> ❑ <br /> STATE-900 <br /> ❑ Aa O FMOkAGDO <br /> D DWRIacf <br /> CIN ME / . STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> dt_11, V CA 7,5a o — <br /> TYPE OF BUSINESS: ❑2 MMBUTOR ❑4 PROCESSOR ✓Boz R INDIAN EPA 10 k p, 5 N 3 (r- k of TANK' <br /> RESERVATION m ❑ / AT THIS SITE <br /> [j1 GAS STATION ARM [:] SOTHEfl I TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAY/ ,NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME W,FIRST) P NE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME // CARE OF ADDRESS INFORMATION <br /> MAILING or STRE ADDRESS A/Box to iMiaate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ' j CARE OF ADDRESS INFORMATION <br /> MAILING or STRE ADDRESS 1 `/(. ✓Box to irxiicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX INDICATING WHICH ABOYB AI DRSSS SHOULD MUSED FOR BOTH I FOAL NOTIFICATION AND BILLING: L ❑ If. ❑ 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 S JURISDICTION F AGENCY F FACILITY ID S M of TANKS of SITE <br /> CIMR OCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITN AREA CODE <br /> 2 l 3 <br /> PERMIT NUMBER PERMIT OVAL DATE PERMIT EXPIRATION DATE <br /> TON ODE_ / . WPE11Y1$OR-DISTR ODE BUSINESS PLAN FILED DATE FILED <br /> ^O� �L:{JJ( ^( YES NO <br /> CHECK I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k SY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1(OR MORE TANK PERMIT FORM 'S'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INF ION LY. <br /> FORMA(3-2-88) - <br /> IY - 1E)" `00, <br />