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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'E `""" `` <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM U �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �rJ ' 11 <br /> ' <br /> S. GM kr +i c <br /> ADDO NEAREST CROSS STREET <br /> m ai 1:1 PARINDW C STATEAGENCY <br /> C CGRPDUiION C LOCAL AGENCY C FEDBaL AGENCY CNONIDUAL <br /> C COUNTY AGENCY <br /> CITYSTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 4a <br /> oi CA 5-110 ZO?- i - o <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION orR of TANK'R <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ NA AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> N a <br /> NI HTS'. NAME(LAST, ST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 6Y-Ilq3o <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME — CARE OF ADDRESS INFORMATION <br /> baviJ e'-�}o o; <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP C STATE-AGENCY <br /> Q C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> �O 11 rt C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE p,WITH AREA CODE <br /> S oe N C4 5x.05 Dq-y6 -W30 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM6 �Q �� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to intlicale C PARTNERSHIP C STATE AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C 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 IMNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. 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 B JURISDICTION R AGENCY k FACILITY ID R X of TANKS at SITE <br /> 5 002 -P> aD 101010101 <br /> CURRENT LOCAEL AGENCY►�Td FACILITY8�ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT NCODE C�EINSUS TRAAC�TTR SUPERVISOR-DISTIIICT CODE BUSINESS PLAN FILED DATE FI/LED /� <br /> 2-sus <br /> OV VES NO a /6 l- <br /> GNECK R PERMIT AMOUNT URCHAIqGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rBr APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.S <br /> F RM A(3-2-88) <br /> DATA PROCESSING COPY <br /> VlY , <br />