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STATE OF CALIFORNN WATER RESOURCES CONTR BOARD <br /> FORM AAI: UNDERGROUND STORAGE TANK PROGRAM 7 �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1:11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> J� & ��r�bmAo <br /> ENCY <br /> ADDRESS^ NEAREST /BOSS STREET ✓fARPORATIGN ❑ LOCAL A�NCY ❑ FEDERAF El STATE L <br /> U'� / — MtK(NlF" Cl INDIVIDUPI ❑ FAUNTY AGENp <br /> h STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> CA 5 3% � - Z-oado <br /> TYPE OF BUSINESS. ❑ 2 pIST IBUFOfl ❑j PROCESSOR ✓9ox it INDIAN EPA ID N N of TANK'N <br /> rLe=1/ RESERVATION or ❑ AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS <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 /> C -T-S) No _ 2 z-O'-b(7 arl7cx/o o� 2 ' -7z3 <br /> NIGH : NAMEILA T.FIRST) <br /> PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> h NO 2 <br /> 11. PROPERTY OWNE0 INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF 99DDRESS INFORMATION <br /> X <br /> M TATvs SNGPl CPAJhmpo <br /> MAILING or STREET ADDRESS ✓�1to irdicale Cl PARTNERSHIP ElSTATE-AGENCY <br /> W17 / [�T CORPORATION 11 LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE it,WITH AREA CODE <br /> CITY NAME <br /> rPNrt, C' <br /> III. TANK OWNER IN ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> STREET AD) S ✓Box to indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> MAILING <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS 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 /> COUNTY M JURISDICTION N AGENCY M FACILITY IDN N of TANKS at SITE " <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMSER " PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> FC"EC <br /> !37ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> r �ZS— YES NO D <br /> BT:�[j� <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If :C� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONP), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / <br /> \ FORM A(3-2-88) J\ <br /> ��- <br />