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STATE OF CALIFORNIA'' WATER RESOURCES CONTROL BOARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"•a^"r" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION +�T M I(� ADDRESS eCi44T NEAREST CROSS STREET ��✓�WM Ra@ 0 PA NSWIIP 0 STATE AGENCY Y]'o:lo ATION 0 LOCAL AGENCY 0 FEUEW AGENCY Cl IINDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE k.WITH AREA CODE CA 01-5ZAC TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR I/Box Box B INDIAN EPA ID ❑ ❑ RESERVATION or - 0o1 TANKS El1 GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(FAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Kor- Ammcbr MAILING or STREET ADDRESS ✓Uofto indcate 0 PARTNERSHIP 0 STATE-AGENCY IO 1,, WCORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY V �/�J 11 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Sr0C,Kl-h&l CA- Q 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Gox to,nd,cate Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 11 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.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. ❑ 11. Ill. ❑ 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# JURISDICTION B AGENCY# FACILITY ID# N o1 TANKS at SITE EE = = I 1 1 /-/ i CURRENT L` L AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE T 'Hfi>1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECKK'# DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAIN FILED NO ❑ DATE F ED �3 - a I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTx Y. \n1 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(3-2-88) `' DATA PROCESSING COPY a /. (4-/(S)