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STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD !?E 1.'` <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° / 10 <br /> �9lIfOR�,P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE NTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME 1-) S . �F,5 <br /> 1/l� .S-faz�haµ <br /> NEAREST CROSS STREET ✓ �m rRATIG ❑ PARTNERSHIP EN ❑ STATFEDEEAGENCY <br /> AGEN <br /> ADDRESS w / �� r` n CAAPoRAiION ❑ LDCALAGENCV ❑ FEDER44AGENCI <br /> S 'j /�-- ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> 7o p�— STATE ZIP CODE �/ SITE PH N,WIIH AFEA CODE <br /> CIN NAME ur CA �n/1 <br /> TYPE of euswess: 2 DISTRIBUTOR a PROCESSOR ✓Boz if INDIAN EPA ID a //� <br /> —FAT TANK'# f <br /> RESERVATION ar ❑ AT THIS SITE / <br /> I GAS STATION F-1 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHO #N(ITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> DAYS: NAME(LAST,FIRS/TT)) T 9 ra/ ia( „(/ <br /> a – 1 III/ ✓ PHONE N WITH AREA CODE <br /> NIGHTS: ME(LAST.FIRST) I PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) '/ <br /> Saw�e <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> S1A/^ CARE OF ADDRESS INFORMATION <br /> NAME / l <br /> O ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESSJ fy,+ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> EIT �-//i7 &�y ❑ INDIVIDUAL Cl COUNTV-AGENCY <br /> STAT ZIP CODE / ��� PHONE N,WITH AREA CODE <br /> CITY NAME _ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRES ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> .I] INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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 /> El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION <br /> AGENCY% FACILITY ID# %ol TANKS at SITE <br /> pb 6S � OU v i <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY to <br /> B� 3 <br /> PERMIT APPROVAL DATE PERMIT EXPIMTI DATE <br /> PERMIT NUMBER / <br /> DATE FILED <br /> RACT# <br /> LOCATION CODE CENSUSTSUPERVISOR-DI Tat CT <br /> CODE BUSINESS SNFILED NO <br /> 23 (�/L, RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> 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. <br /> FORM A(3-2-88) • <br /> � DATA PROCESSING COPY <br />