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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"•�a"'" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Y CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .15 O � I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS IN ORMATION a k rRr� ' ac ADDRESS NFF EST CROSS TREET ✓ bORKTO ❑ LOCA.AEHIP ❑ FIEDU AGENCY DRRJJ++ olo,da,ax ❑ PARTN IP ❑ FLVEEA690a ❑ INDINDUAL ❑ COUNi AGENCY CITY NAME / STATE CODE SITE PHONE N,WITH AREA CODE Sf� TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID nRESE � M of TANK't E] 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSTMLANDS ATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYSNAME FIRST) PHONE N WITH AREA CDE G N � THN � T NIGHTS AME(LAST.FI ) PHONE#WITH AR7A CODE NIGHTS'- NAME( ST,FIRST) PHONE 4 WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NA— CARE OF ADDRESSI FORMATION 0OC- MAILING or BTREET AD75 L -/Box to intlicale ❑ PARTNERSHIP 11 STATE-AGENCY C Sd- ❑ ORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY : 11 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME 91 TE ZIP CODE PHONE#,WITH AREA CODE �oc 20?-`/-G6- 86 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY _- ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. 111. ❑ li 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 R JURISDICTION N AGENCY N FACILITY ID N k of TANKS at SITE In 10 1-2EKE ® a 10 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE VOWP12z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESSIP S N❑FILED NO ❑ /D'A�ILED 1 .23, 60 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k lam/ B 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. / / � FORM A(3-2-SB) `J / �,� DATA PROCESSING COPY `�