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STATE OF CALIFORFV1 WATER RESOURCES CONTIOARD111 13 <br /> FORM AA': a '� <br /> \ UNDERGROUND STORAGE TANK PROGRAM <br /> SITE r\ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Y� iC <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE "'FOR <br /> MARK <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT E95 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSE 7E IV <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) a <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ED u. a eN <br /> ADDRESS NEAREST CROSS STREET ✓Sw ID iMipa ❑ PAAMERSHIP ❑ STATEAGENC! <br /> 3 / ❑ CORPORA71ON Cl LOGLAGDO ❑ FEDEML.AGENCI <br /> L• C ❑ NONIWAL ❑ COJN AGENCY <br /> CITYNAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> ar_ ry CA gs2os ,Zo - /�-Dols <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IO N <br /> ESEL7I Cm1SSTATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ 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 /> 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 /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL�AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INOIVIDUAL Cl 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 ADDRBBB 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 /> CO3OUNTY R JURISDICTION k AGENCY N FACILITY ID N C k o1 TANKS at SITE <br /> CURRENT <br /> �AGENCY FACILITY <br /> � � APPROVED BY NAME � / J PHONE N WITH AREA CODE r' I <br /> (y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> �A t�LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] NO 11 / v 7{. <br /> `.!� N"""i PERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 11BY: <br /> M <br /> pRM MUSEACCOMPANIE AT LFART(1)QR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS °F <br /> ANGE \ TE INFORMATION ONLY. �. <br /> 3-88) �— ��— <br /> 1DATA PROCESSING COPY j 1� <br />