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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM u >> mo SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONIr ; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 6a C- lio-e ADDRESS NEAREST CROSS STREET ✓BoobbBrale D PARTNERSHIP D STATE AGENCY [ICOWCRAIION ❑ LOCAL-AGENCY ❑ FEDEIUL.AGENCY !/ U ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME n / I STATE ZIP CODE SITE PHONE A,WITH AREA CODE CA I 93/-316 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 P SSOR ✓Box if INDIAN EPA ID a N of TANK's //llam� RESERVATION Or F-1 AT THIS SITE L/ ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOYB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III. ❑ 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 S JURISDICTION Al AGENCY M FACILITY IDR E of TANKS at SITE " / 151115f1 1 1 1 �0 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOLCOMDE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLALFIUD DATE R!D4-n �1 �r'yla� YES �CHECK NPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 INFO FORM A(3-2-88) / _\ �!