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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM AAP: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T P V CLOSED SITE F+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 ­4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME ?"Verf3-olq <br /> CARE OF ADDRESS INFORMATION Fi <br /> ADDRESS n NEAREST CROSS STREET �kl help ❑ PMTNFASHIP ❑ STATE AGEN <br /> 2, DV6eAORATION ❑ LOCAL AGENCY ❑ fEOFRAL-AGDENCY <br /> INGmouu ❑ camnAGEHcv <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> CA h'3� <br /> TYPE OF BUSINESS: ❑2 STRIBUiOR ❑ I PROCESSOR '/Box if ND14N EPA ID N <br /> ❑ <br /> 7 GAS STATION 3 FARM S OTHER RESERVATION or - If of TANK'N❑ 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 /> GOST�7 Ive3ely <br /> NIGHTS: NAME(I_AST.HRSV PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> 5a4w �� � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> II. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^^--� II Q� r CARE OF ADDRESS INFORMATION <br /> 0 <br /> MAILING or STREET ADDRESS ✓Sax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> �. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ❑ III. ❑ <br /> 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 N JURISDICTION K AGENCY N FACILITY ID N N o1 TANKS at SITE <br /> M = o <br /> CURRENT LOCAL AO Y FACILITY ID M��� APPROVED BYNAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION O CENSUS TR N 2 ' SUPERVISOR-DISTRICT CODE BUSINESS PLAIN FILED NO <br /> ❑ OATE FILED1057" _/� <br /> CHECK• PERMIT AMOUNT �/S SURCHARGE AMOUNT Z FEE CODE RECEIPT It <br /> as <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS AGE OF SITE INFORMATION ONL�--� <br /> RM A(3-2-88) J <br /> DATA PROCESSING COPY <br />