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STATE OF CALIFORNIA., WATER RESOURCES CONTROL..eARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I C <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN LOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 9 N <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS //�' - NEAREST CROSS STREET ✓BmRIiOWe Cl PARTNEAS'W 0 STATEAGDCf <br /> 5D0 V✓ r /" sT 0 MIPM11011 0 MAL AGFNLY 0 RDSK AGE10 <br /> 0 INIWDIIN 0 COUMAGENCY <br /> CITY-NAME- --- STATE ZIP CODE SITE PHONE It.WITH AREA CODE <br /> -- -- -- -- - CA �s 3 7� 2a9— 8331-5'�S° <br /> TYPE OF a S NESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it I IAN EPA ID N <br /> RESERVATION or M of TANK's <br /> I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Be.✓ to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 /> COUNTY A, JURISDICTION a AGENCY k FACILITY ID If #of TANKS at SITE <br /> 3 9 <br /> CURRENT LOCAL AGENCYCILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> n <br /> K 5/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION TRACryT a C DE CENSUS SUPERVISOR-DI TILICT CODE BUSINESS PLAN FILED DATE FILED y/ q <br /> Z 0(� YES [-] NO E] _j5— —/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> UV <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 /> FORM A(3-2-83) <br /> �, DATA PROCESSING COPY r <br />