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�/ 4P'iv Oxn.SAE.. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL Bt)ARD ' <br /> FORM AAI: UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE A- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ';� 1 <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE c""J'`"'�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PJAMAgLNTLY CLOSED SITE l'-4& <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) <br /> !V <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) p. <br /> FACILITY/SITE NAME p T�7 CARE OF ADDRESS INFORMATION <br /> 1-O V (- <br /> ADDRESS .,..� A <br /> ENEARESTROSS STREET ✓f PS P � A1E-A��PnMM IOG GEN Y O IDEPAI GEHCINDMDU& 0 o3UNTY-AGENCYCITU NAME 1 ZIP CODE SITE PHONE N,WITH AREA CODE <br /> V <br /> I� ( <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR -/Box iI INDIAN ❑ EPA IDN N of TANKS <br /> 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE;WITH AREA C ICE DAYS: NAME(LAST,FIRST) PHONEY WITH AREA CODE <br /> DAYS; N E(LAST,FIRST) PHONE <br /> `J U11L/ U Uv_ <br /> Pv(LO �Ai�a pryONEp WITH AREA CODE <br /> NIGHTS: ME(LAST,FIRST) PHONE.WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNN-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CIN NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /ti _ ^ CARE OF ADDRESS INFORMATION <br /> I�l'(/IFnPA`pj 1�� <br /> ox to indi D PARTNERSHIP 0 STATE <br /> ENCY <br /> MAILING or STREET ADDRESS ✓ ORPORATION 0 LOCAL AGENCY ❑ FEDERAL--- <br /> C <br /> O CO AG NCV <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH 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 /> ffOPERNITAMOUNi <br /> JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE <br /> Y FACILITY IDD N/� APPROVED BY NAME PHONE N WITH AREA CODE <br /> 1 \1 \G�PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT C E BUSINE88 P SNFILED HG DATE FILEDPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. <br /> aaaaaaaam <br /> 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. (\/� <br /> FORMA(3-2-88) 7 <br /> DATA PROCESSING COPY <br /> i <br />