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STATE OF CALIFOR <br /> WATER RESOURCES CONTROL BOARD �z"c"'':' .'F <br /> FORM AA': ` <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 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 w <br /> CAJ <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) OD <br /> 00 <br /> FACILITY/SITE 7E CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmbibcale ❑ PARTNERSHIP 0 VATE-AGENCY <br /> 0 CCGPORATION 0 LOCAL-AGENCY ❑ PMEW-AGENCY <br /> 31 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME C/ STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> �t CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box#INDIAN EPA ID N <br /> ❑ 1 GAB STATION 3FARM 5OTHER RESERVATION or If of TANIVs <br /> ❑ ❑ TRUST LANDS ❑ 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE H,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. ❑ 11. ❑ 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# JURISDICTION# AGENCY M FACILITY ID M R of TTA�NK$at SITE <br /> C� U 1 V V <br /> CURRENT LOCAL AGENCY FACILITY ID M L I 1 , 1 1 3 APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATr5CtDE CENWSTIIACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> vv �JJ- )_0 YES NO Z0J/?01 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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 INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> V , DATA PROCESSING COPY <br /> ■ <br />