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STATE OF CALIFORNIA WATER RESOURCES CONTROL :D oF' ,Ne FORM AA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION :! " COMPLETE THIS FORM FOR EACH FACILITY/SITE �`11F.R=�P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ rQ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE j—� 00 00 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) fat FACILITY/ ITENAME -T CARE OF ADDRESS INFORMATION V'\ i�ec Q ADDRESS ( NEAREST CROSSSTREET ✓GaVoirouta C PARTNERSHIP 0 STALE-AGENCY 1 1 Cl CORPORATION C ClLOCAL AGENCY FEDERAL-AGENCY A.Aft_� C INDIVIDUAL 0 COUNTY-AGENCY CITY NAM STATE ZI fY p , SITE PHONE X,WITH AREA CODE (_}1�3�1� ao"i 3 l TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N X of TANK's ❑ 1 GAS STATION E]3 FARM 6 OTHER TRUSTVATION LANDS o ❑ AT THIS SITE _�3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION C LOCAL-AGENCY 0 FEDERAL-AGENCY C INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP C STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY C INDIVIDUAL C COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE)1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. II. El 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYA, JURISDICTION X AGENCY a FACILITY ID M X o1 TANKS at SITE c 101 CURRENT LOCAL AGENCY FACILITY IID# APPROVED BY NAME PHONE X WITH AREA CODE LEL PERMIT APPROVAL DATE PERMIT EXPIRATION DATE X� SUPERVISOR-DISTRI T CODE BUSINE58 PLAN FILED DA /YES NO NT SURCHARGE AMOUNT FEE CODE RECEIPT X 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. 1 FORMA(3-2-88) • \ 'wI DATA PROCESSING COPY