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STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMA E �. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,Sl <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME _CARE OF ADDRESS INFORMATION <br /> /l_a 't -5 " <br /> ADDRESS NEAREST CROSS STREET ✓B whd s@ D PARTNERiHIP D STATE-AGENC/ <br /> {, // ❑ C/�R70AATION D LOCAL-AGENCY D RTIEML AGDa <br /> C . SC U' fs�S �Dj ❑ INDMOIIA D fXlON1Y-AOENLY <br /> CITY NAME STATE ZIPOODE SITE PHONE It,WITH AREA CODE <br /> -51y ck/-o,-, CA Ysaol �212 X67-sys/ <br /> TYPE OF BUSINESS: 2 DISTRBUTOR 4 ✓Boz N INDIAN EPA ID N M of TANK's <br /> 1 GAS STATION ❑3 FARM ❑ OTHER TRUSTLANDS <br /> or ❑ <br /> 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 k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> d s RR <br /> MAILING aSTREET ADDRESS ✓ t°mdtl le D PARTNERSHIP - D STATE-AGENCY <br /> S / CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME STATER ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING wSTREETAODRESS ✓ xto md,cele D PARTNERSHIP DSTATE-AGENCY <br /> S CORPORATION ❑ LOC TL ❑ FEDERAL-AGENCY <br /> Sh,el� NDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE <br /> Z-05 0,4 gaoYC) <br /> P137-SYYi <br /> IV. LEGAL NOTIFICATION kND BILLING ADDRESS <br /> CHECK ONE(1)BOX 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 R JURISDICTION P AGENCY M FACILITY ID K N of TANKS M SITE " <br /> 39 � � oo " i � 0 1 © 0 <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> 5,q lAV <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK <br /> CATION CODE CENSUSTRACTN BUPERYISORA18T111CT CODE BUSINESS PLAN FILED DATE FILED <br /> e> 'i flZJ ja YES NO s O <br /> N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <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 INFORMATIONBN6II, <br /> FORM A(3-2-88) \ <br />