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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM =" Ga <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> a . ! COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / GZ_ <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> SµAw vf-�°— v N co- TntG <br /> ADDRESS NEAREST CROSS/STREET ✓ExroMm 0 PARTNERSHIP 0 STATE AGENCY <br /> —C/{j (`I- G7�WY'A4 Wr'T I • 'O•�'1 IC DMDUALION O E� -AGENLY AGENCY ❑ AGENCY <br /> AGENL <br /> El <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> sTfl�-l�`TON CA a52oJaK3-6a�s� <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA IDN M of TANII �/ <br /> ❑ ❑ � TRUST LANDS TION o ❑ /�• <br /> 1 GAS STATION 3 FARM 5 OTHER 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 /> 5 v cvr/',�-//141 ztya) 03-694K <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 /> G - SI4A-6vji6Q_ <br /> MAILING or STPEET ADDRESS ✓Box to i rdloste ❑ PARTNERSHIP 0 STATE-AGENCY <br /> �y/ (�/J,�.Q/) D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> `�[6 14PD1'VW � 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> S'rOG4111-mt4 L4— <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to md,cale 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it, ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS BI SITE <br /> EEI 1 od / 5Z5 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> s� wV <br /> '-\ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> \ LOCATION CODE CENSUSTRAgIS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED Dm <br /> v ?jZ� YES E] NO CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> j <br /> THIS FORM MUST BE ACCOMPANIED BY AT LFA—�)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.C`",'A <br /> 7.. <br /> \ FORMA(3-1-85) `_ n <br />