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STATE OF CALIFORNIe WATER RESOURCES CONTRolt4oARD 9t '""` <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM V <br /> .m� NL <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 'o <br /> C COMPLETE THIS FORM FOR EACH FA ILITY/SITE .oa"'" <br /> MARK GNLY F-11 NEW PERMIT F-16 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) R W <br /> ? cG <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> 1 ADDRESS �(^^ NEAREST CROSS STREET ✓CO6POR4➢DN 0 Iw El AART FAG IRILY ElSTAH AGDO-P ENLY <br /> C- ear ❑ INDNIDUu ❑ CD3NDAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ #of TANK'N <br /> 2 DISTRIBUTOR ❑ 4 P SMR ✓Box if INDIAN EPA ID a Db <br /> RESERVATION or O <br /> ❑ 1 GASSTATION [:] 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> erg �1i e 5/S<3�56 <br /> NIGHTS: NAME(LAST.F RST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /:2 <br /> MAILING or STREET ADD ESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> C0 CORPORATION Cl LOCAL-AGENCY 11FEDERAL-AGENCY <br /> Q ,JWWI- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE 21P CODE PHONE a.WITH AREA CODE <br /> tia CA 37 toy SS6 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1f.0� <br /> MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.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. ❑ It. Ill. ❑ <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# JURISDICTION a AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> mI I I ivo � I I I Dl— <br /> CURRENT <br /> LOCAL AGENCYAACILITY IDD# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED LIL <br /> 00 YES NOCHECKN PEflMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMITO RM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SS) - <br /> � DATA PROCESSING COPY <br />