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STATE OF CALIFORNIA WATER RESOURCES CONTROL _JARD '341 FORM AA': UNDERGROUND STORAGE TANK PROGRAM a Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C wP- to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 25 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED_WE ~ ONE ITEM ❑ 2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 w I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) pop FACILITY/SITE NAME CARE OF ADDRESS INFORMATION (Y1 I S S i o n Gro ADDRESS (^J NEAREST CROSS STREET ✓BKR�61sN 1:1PAIT"CISNP Cl STATE.AGEICY '1 El 00110 LGM411NIX 0 REFPALV00 ❑ INDNDW 0 OXNIIY Amcr CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE pS �OC�"fir CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR -/Box N INDIAN EPA ID N _ N of TANK'S ❑ SERVATION 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRRUSTT LANDS w ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,RRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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. ❑ IL ❑ Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY E FACILITY ID N N of TANKS at SITE O U 1 O O 1 U 1 U CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE missl io PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSU^S�TR2ACT Nom�\\ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED V , C'T L7 8b ( YES NO ❑ oZ `� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: xx JTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION OHL `FORM A(3-2-88) J /).� _N DATA PROCESSING COPY / -�.�-