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STATE OF CALIFORNIA WATER RESOURCES CONTROL'BOARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM u �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE °^<,.ovB�Y MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE jgk I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FACILITY/ TE NAME CARE OF ADDRESS INFORMATION ADDRESS JNEAREST CROSS STREET I ✓GMMYd®le D PMRNRSIIP D SrATEAGDo l� /� D CCIPGRATION D LGCAL�AGDO D FEMPALAGENCY A LjoA.J— ( D INGMDUN D WUW.AGBCY CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑4 PROCESSOR I -/Box R INDIAN EPA ID x ❑ 1 GAS STATION FARM ❑50THER RESERVATION LANDS or If Of TANK's ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 inchoate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ II. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRIMED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYY## JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE —I CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE T PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED YES No ❑ 3/ CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: / 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. /FORMA(3-288) 11'/,X,•V/// DATA PROCESSING COPY