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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD 5` FORM `AA: UNDERGROUND STORAGE TANK PROGRAM Q SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C) I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMEI COMPLETE TH15 FORM FOR EACH F ILITY/SITE�^Asoxp�e S MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT I 5 CHANGE OF INFORMATION ❑ 7 PEtaaUkINTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Thr NEAREST CROSS STREET ✓Bw bvNKae EASHIP ❑ STATE AGENLY ❑ W180RATION LOCI AGENCY ❑ REDEML AGENCY I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMEI CARE OF ADDRESS INFORMATION S CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS SG1n �. u El CORPORATION LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS Cl INDIVIDUAL COUNTY -AGENCY Thr NEAREST CROSS STREET ✓Bw bvNKae EASHIP ❑ STATE AGENLY ❑ W180RATION LOCI AGENCY ❑ REDEML AGENCY 111 or {G 1 /�� ❑ INDIVIWAI COUNTY AGENCY CIN NAME SURCHARGE AMOUNT - / STATE ZIP C (/A AE��616 I SITE PHON`#, WITH AREA CODE BY. �Vves TYPE OF BUSINESS: F-1❑ 2 DISTRIBUTOR 4 PROCESSOR '/ Box it INDIAN EPA ID p ❑ I GAS STATION ❑ 3 FARM E:15 OTHER ESERTION TRUST LANDS o ❑ P of TANK'a -I AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: N E (LAST, FIRST) PHONE p WITH AREA CODE YS: NAME (LAST, FIRST) PHONE At WITH AREA CODE N 3co I K0 tj9— r --i zEz I NIGHTS'. NAME (LOST, FIRST)l PHONE N WITH AREA CODE NIGHTS. NAME (LAST, FIRST) PHONE # WITH AREA CODE C II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S� as FACILITY ID N K of TAAN^^KS at SITE v O V MAILING or STREET ADDRESS ✓Box to indicate ❑ RTNERSHIP 11STATE-AGENCY 1 JJ r V El CORPORATION LOCAL -AGENCY ❑ FEDERAL -AGENCY CITY NAME A/STATE Cl INDIVIDUAL COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE p, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETEDI NAME P/ s1 5-7�06&—Allv' vivT S rARE OF ADDRESS INFORMATION AGENCY N FACILITY ID N K of TAAN^^KS at SITE v O V MAILING or STREET ADDRESS 1ARTNERSHIP ✓ GO. to intlicate ClSTATE-AGENCY ClClCORPORATION LOCAL -AGENCY ❑ FEDERAL -AGENCY 1 JJ r V ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME A/STATE [.� l ZIP CODE� PHONE p, WITH AREA CODEjr IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY N FACILITY ID N K of TAAN^^KS at SITE v O V CURRENT LOCAL AGENCY FACILITY ID N / Q l APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE DE LCHECKO CENSUS TRACE#! 2 3 v a SUPERVISO`F.?ISTRICT CODE TZ0 BUSINESSPLANFlLED YES ❑ NO ❑ DATE FILED y 3 7 (/ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT K BY. �Vves F" LD A d! THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. G / FORM A(3 -2 -RB) 1VJ.111iA/�/_J1((J, DATA PROCESSING COPY