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STATE OF CALIFORNIX" WATER RESOURCES CONTROCSOARD <br />FORM AA': UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />F <br />i <br />' m Z0 <br />to <br />1-1 COMPLETe THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ I 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 63 <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETEoi <br />FACILITY/SITE NAME p- <br />CARE OF ADDRESS INFORMATION' <br />CARE OF ADDRESS INFORMATION <br />Pr,E P lYA/lC <br />3 S )y(/� <br />1:1CORPORATION ❑ LOCAL -AGENCY ElFEDERAL AGENCY <br />ADDRESS <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />NEAREST CROSS STREET ✓BwW Wane ❑ PARTND011P ❑ STATE AGENCY <br />/�� <br />ZIP CODE PHONE N, WITH AREA CODE <br />❑ C/JRPDRATIDN ❑ LDCAL-AGENp ❑FEDERAL AGENCY <br />ZIP CODE PHONE N. WITH AREA CODE <br />❑ INDIVIDUAL ❑ WUNTY AGENCY <br />CITY NAME <br />SUPERVISOR -DISTRICT CODE <br />STATE ZIP CODE SITE PHONE N, WITH AREA CODE <br />^' <br />CHECK N' <br />CA 52-36 <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />—14 PROCESSOR <br />✓Bax if INDIAN <br />EPA ID A <br />❑1 GAS STATION 3 FARM <br />❑ <br />❑ 5 OTHER <br />RESERVATION or <br />❑ <br />- <br /># of TANK's <br />TRUST LANDS <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE If WITH AREA CODE <br />NIGHTS. NAME (LAST, FIRST) PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION A ADDRESS — !MI IST RW enAAol Wren% <br />NAME <br />�k RQ��GL <br />CARE OF ADDRESS INFORMATION' <br />MAILINGor STREETADDRESS <br />✓Box to,rd,cale Cl PARTNERSHIP 11 STATE -AGENCY <br />3 S )y(/� <br />1:1CORPORATION ❑ LOCAL -AGENCY ElFEDERAL AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N, WITH AREA CODE <br />STATE <br />ZIP CODE PHONE N. WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETF+Di <br />NAME <br />CARE OF ADDRESS INFORMATION <br />4 <br />FACILITY ID If <br />MAILING or STREET ADDRESS <br />I/ B.. to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION Cl LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />PERMIT NUMBER <br />❑ INDIVIDUAL ❑ COUNTYAGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N. 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. ❑ II. V1 Ill. ❑ <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 # <br />JURISDICTION Al <br />AGENCY # <br />FACILITY ID If <br /># of TANKS at SITE <br />(0 1 G 0 <br />CURRENT L 110ENCY FAC Y ID # <br />APPROVED 8Y NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT#- <br />S— <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES NO <br />DATE FI ED <br />CHECK N' <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT If <br />BY: <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (3-2-98) <br />DATA PROCESSING COPY <br />r <br />v <br />A <br />