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.� ���,�.�.-� ...n-..��r,B!•.vr �.p9RMy)y.yyCy� " Tlr"`.n � T �1aT' -„Ty:: . . r <br /> P <br /> STATE OF CALIFORNIA ' WATER RESOURCES CONTROL BeARD <br /> s <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM ” <br /> =mom <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Ln <br /> cc <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> �N <br /> ADDRESS /-IF IF NEAREST CROSS STREET ✓fxxw K ❑ PARMEASHIP ❑ STATE AGENCY <br /> ( S`S� O MIPOINDRIDRAA� O �GIBICYCR+a ❑ gnu-AGENCY <br /> CITU NAME STATEZIP CODE SITE PHONE p,WITH AREA CODE <br /> v �DA� CA 213.E <br /> TYPEOFEIUSINESSI <br /> ❑�DISTRIBUTOR F74PROCESSOR ✓Box if INDIAN EPA ID If _ pof TANK's <br /> ESERVATION <br /> ❑ I GAS STATION r l 3 FARM ❑ 5 OTHER TRUSTT LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE if WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING&STREET ADDRESS ✓Box la indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP C95_20 PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> L S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIRBS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION R AGENCY* FACILITY ID 11 Al at TANKS at SITE <br /> ® = = I I 14/17/ Ta ® p D 1 <br /> CURRENT LOCAL AGENCY FACILITY ID It _ - ^ APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E CEN8US TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> Z . Z 2 YES [ NO G11S <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: <br /> aaaaaaa <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 INFORMATION ONLY. <br /> FORMA(3-2-BS) <br /> DATA PROCESSING COPY -5 <br />