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Y . STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD FORM AAI: SITEI UNDERGROUND STORAGE TANK PROGRAM ( l l FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONII r, o COMPLETE THIS FORM FOR EACH FACILITY/SITE OeN�P MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT LL]5 CHANGE OF INFORMATION ONE ITEM ❑2 INTERIM PERMIT ❑ 7 PERMAN SED SITE F-a ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) O F CIL E NA� CID J J CARE OF DORESS INFORMATION ADDRE NEAREST Sb ,VCo A�oNq,oN o Long gIP ❑ STgtE-AGENCY AGENCY o FEDFRc CITY NAME ❑ INGMBGPL ❑ CpGN AGENCY Ca STATCA ZIP CODE �0 TE PHO E p WITH AREA/O E t S 3 Z TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID Al ❑ 1 GAS STATION ❑ 3 FARM 05 OTHER RESERVATION or ❑ t i a Aof TANK'S �/1 — TRUST LANDS IV AT THIS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY ME(LAT,fIRSTI PHONE p WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONE a ITH AREA CODE CC o �_ ((//CCs K/ll � q NIGHTS: NA E(LAS ,FIRST) PHONE p WITH AREA CODE NIGH AME(LAST,FIRST) PHONE WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME SV CARE OF ADDRESS INFORMATION l MAILING or REET ADDRESS/`•-�Vw. ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE 0 10 1 T o U CURFD 7r;CY FACILITY IDN APPROVED BY�MPHONE#WITH AREA CODE PERMIT NUMBER 1` PERMITIAPPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED UYES NO CHECK# PERMIT AMOUNT SURCHARGE iMOUNT 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 FORM A(3-2-88) IMF DATA PROCESSING COPY r/