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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD %'` <br /> FORM AA': <br /> UNDERGROUND STORAGE TANK PROGRAM s4 wa <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 E] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 1NTEflIM PERMIT q AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C[ <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION V <br /> ADDRESS NEAREST CROSS STREET ✓Bu wmaw 0 RARTNERSNP 0 STATE AGENCY <br /> ���� ❑ IND WA'MWORATID ❑ CWNiKRGENLy FEBERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: p DISTRIBUTOR d PROCESSOR ✓Box it INDIAN EPA D nA <br /> 1 GAS STATION 3 FARM 5 OTHER RESETRUST <br /> YLANDS ATION or ❑ X of TANK4 <br /> AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box la Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALADEN0 STATE-FEDERAGENCY <br /> AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9.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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 13CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL 0 COUNN-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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: 1. 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 M JURISDICTION 11 AGENCY k FACILITY ID B If of TANKS at SITE <br /> I I I / =(o�l <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE N WITH AREA CODE <br /> EPERMITBERFPERMIT <br /> PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> ODE CT Y SUPERVISOWDISTRICT CODE BUSINESS PLAN FILED DATE FILE h' <br /> YES NO <br /> CHECK a UNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY. •r <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(3-2B8) • <br /> �J <br /> v DATA PROCESSING COPY <br />