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STATE OF CALIFORNI'A'N' WATER RESOURCES CONTROriOARD a <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE A— FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE —4 <br /> MARK ONLY ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE __j� <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME r.('i. —/ 11SON <br /> E-• Jam( /_ <br /> Al NEAREST CROSS STREET wndrace ❑ PMTNERSHIP ❑ STATE AGENCY <br /> ADDRESS6 G ❑ LOCAL-AGENCY ❑ FEOiRL-AGEC <br /> NGM...., ❑ OUAn"C <br /> CITY NAME STATE ZIP CODE / SITE PFI'y�.WITM AREA CODE <br /> /2 G CA // U(/ <br /> TYPE OF BUSINESS: ❑2 D UTOfl ❑ 4 PROCESSOR V Box INDIAN REIf of TANK's SERVATION or EPA D p _ AT THIS SITE 3 <br /> ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> l7i'. �I& <br /> O M N PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LASE FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Soz 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to,ndicale Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N M o1 TANKS at SITE <br /> CURRENT LOCAL AD FACILITY IDN APPROLNA PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE DATELOCATION CODE CENSUS TRACTN SUPERVISOR-DISTR CODEDDATE FILEDM <br /> �12 NO �CHECK# PERMIT AMOUNT SURCHAR EAM UNT ECEIPT# / <br /> WTHIS 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-BS) 1 <br /> �'�' DATA PROCESSING COPY <br />