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Se'aua� �M1 'I <br /> STATE OF CALIFORNIA' WATER RESOURCES CONTROL ARD �� <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM �a Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE °+ ,Few Hae <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 P ENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ <br /> ❑ ❑6 TEMPORARY �I <br /> 2 INTERIM AMENDED PERMIT <br /> PERMIT 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) All. <br /> FACILITY/SITE NAME O <br /> / So CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bm W-ooak 0 PARTNERSHIP 0 STATE AGENLY <br /> l / 0 COWORATILOGALCENCI FEDL.AGENLY <br /> ❑ ON 0 0EPA <br /> INDVIGUAL ❑ WONIVAGENCI <br /> CITY NAME �� STATCA ZIP CODE SITE PHONE#,WITHA AREA CODE <br /> TYPE OF BUSINESS: 2 TRIBUTOR ❑ 4PROCESSOfl ✓Box if INDIAN EPA ID # <br /> ❑ I GASSTATION 3 FARM ❑ B OTHER RESTRUSTYLANDS ATION or ❑ a of TANK'F <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE I WITHAREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Or 1/////// (�x <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> .5�+•e �s Z <br /> MAILING or STREET ADDRESS ✓Box to iftcate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTYAGENCY <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 /> See �S �- <br /> MAILINGorSTREETADDRESS ✓Box to,Pdrrate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHCNE#,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. 11. ❑ 111.❑ <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 R JURISDICTION R AGENCY N FACILITY ID R R of TANKS at SITE <br /> [Im 101 b 1 Z/1 0 10 10 <br /> CURRENT LOCAL AGEYpACIL�00_ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER (/J� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI;FIDE CENSUSTRACT# SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATE FILED <br /> / 'Ji 2.Z 3 YES NO �07 <br /> CHECK PERMIT AMOUNT SURCHARGE AlAOUNT FEE CODE RECEIPT# BY: <br /> as <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(3-2-88) <br /> DATA PROCESSING COPY <br />