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y�r i•6:: ��e <br /> STATE OF CALIFORNIA- WATER RESOURCES CONTROt-dOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM =" z <br /> SITEn ' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> V �9lIFOPH'P <br /> COMPLETE THIS FO M FOR EACH CILITY/SITE <br /> 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'J <br /> MARK ONLY ❑ N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE qq <br /> (p <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Fj <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> T <br /> ADDRESS NEAREST CROSS STREET ✓Boxb#dole PABTNENSNV CSTATE-AGENCY <br /> ❑ CGPOBAGDN ❑ LOCALAGi 0 RDEBAL AGENCY <br /> C INDMDUAL 0 COU111YAGBICY <br /> CITY NAME I / STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> J CA <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # k of TANKY <br /> ❑ ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑ I GASSTATION ❑ 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERALAGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate C PARTNERSHIP ❑ STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BETH LEGAL NOTIFICATION AND BILLING: L ❑ if. ❑ III.❑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# JURISDICTION M AGENCY# FACILITY ID If #of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> Nec--rim in <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> YES � NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM BE ACCOMPANIED BY AT LEAST M OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> .� \F RMA(3-2-88) <br /> � DATA PROCESSING COPY Jc / <br />