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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM AA': UNDERGROUND STORAGE TANK PROGRAMA. ITE FACILITY/SIT SE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE o ' I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) G W FACILITY/SITE NAME � CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bwib4'drsk ❑ `WNUSHIP ❑ STATE-AGENCY /S ❑ OOWOPATION ❑ LOCAL-AGENCY ❑ FEDENALAGENCY 0 INDMDIAL Cl CDATv AGENCY CITY NAME STATE ZIP CODE SITE PHONE X,WITH AREA CODE CA f 3 3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID N 0 o TANKY ❑ 1 GAS STATION ❑ 3 FARM 1:1 5 OTHER TRUSTYANDS EATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE*WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE*WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓B.x(.Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ II. ❑ 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 X JURISDICTION* AGENCY X FACILITY ID X X of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY M PHONE X WITH AREA CODE PERMIT NUMBER PERMIT AP 0�VVAL,,D'AATIE MIT EXPIRATION DATE d� LOCATION CODE CENSUS TRACT XSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: \\1 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(3-2418) - ` fir' DATA PROCESSING COPY