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or <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM AA': =mom �m <br /> UNDERGROUND STORAGE TANK PROGRAM ® o <br /> SITE —LC—] FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAJOSE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATIONS ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N I�L�1P r�rvM<�s <br /> ADDRESS NEAREST CROSS STREET ❑✓�MWOR TNM 0 LOCI 0 SrATE AG90 <br /> (MAL-AWO <br /> 0000 E - IfflRT[—/C_ R—! ❑ INDMIWAL ❑ D Mtt-A(ENp <br /> CITY NAMESTATE ZIP CODE ITE PHONE*,WITH AREA CODE <br /> C CA 153 � 1 6 5,;0 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR d PROCESSOR ✓Box if INDIAN EPA ID N _ S of TANK'* <br /> RESERVATION or F-1 <br /> AT THIS SITE <br /> I GAS STATION 3 FARM 5 OTHER TRUST LANDS <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 /> CI CJZC i SiiL- o?C r 81'6-51-57 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> SLS Otto L/<- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SCLn� GAS �o✓e <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,5a7,je as 2hot/e. <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 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: L ❑ I. ❑ 111. El <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 R JURISDICTION Is AGENCYR FACILITY ID* 0 t-{ E of TANKS N SITE ' <br /> CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE F WITH AREA CODE <br /> I>_L : '28 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> IC <br /> OCATION COOS CENSUS TRACT N SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a6 YES NO /� 7/9u <br /> HECK P PPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM AB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(32-88) <br /> I , C <br />