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STATE OF CALIFORNI*w WATER RESOURCES CONTROYCI6OARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) ~ O FACILc0I S��SITE NAME od; 1 �t 1 CARE OF ADDRESS Com 'I �\ V Qn✓t,i ADDRESS NEAREST CROSS STREET ✓ftondiUN 0 PWxESllP 0 STATE QftI PGCE C� C { 0 COIPORAnox ❑� L��JJt1Ace1CY 0 FE VIAL AGM 31 A E ❑ INGMWA I�Q Y AGENC CITY NAME Lod CA STATE ZINC ;qqU SITE PHONE p,WITH AREA CODE 1Z`'L TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 0INDIAN EPA ID R (�-]]1I FF..JJ:: «flof TTAANK'sRESERl /� l ❑ 1 GASSTATION ❑3 FARM OTHER TTRRUSTVLANDS ATION GF ❑ � AT THIS SITE ( v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME 1 I pp [i CARE OF ADDRESS INFORMATION `,,Odl '(.�nl �J?.rX MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY SIC � _ (� Or� D CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY .i oL D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,q52 WITNAREA CODE<( 1 9 5 3 SSaB 1 Ill. TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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: I. ❑ it. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION B AGENCY B FACILITY ID If a of TANKS at SITE 3H 100 I A I C) a -1 I 1 00 16d CURRENT LOCAL AGENCY FACILITY 10 a APPROVED BY NAME PHONE k WITH AREA CODE 1,011 31 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK07 QE CENS T N SUPERVISO Ii7Al¢T CODE BUSINESS PUN FILED ❑ DA FILED /.j\ c�U` (�J YES NO ' PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST"'OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 FORM A(3-2-BB) ,�\ �^ DATA PROCESSING COPY