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STATE OF CALIFORNIA" ' WATER RESOURCES CONTROL`RdARD F <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE Z FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -' : o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��Foax`' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> A <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILI NAME j(f�W CARE OFA DRESS INFORMATION .06 <br /> ADDRESS Np L✓ SGPo . Cl PARTNERSHIP ❑ STATE-AGENCY <br /> IDN ❑ LOCAL-ACRICY ❑ FWX AGENCY <br /> 7N 11 <br /> INDMDUAL ❑ DDUNTY AGENCY <br /> CITY NAME 1 STATE ZIP CODE SITE PH E N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box i11NDIAN EPA 10 If <br /> F-] 1 GAS STATION ❑3 FARM OTHER RESTRUSTYLANDS or ❑ A, A. ATTHISSITE 07_-- <br /> EMERGENCY <br /> 7/EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAV :�E(LAST,FIRST - P ONE N WITH AREA CODE DAYS: NAM (LAST,FIRST) p NE k WITH AREA CODE <br /> (`'�- 2.0, 33(/-4000 MST <br /> S <br /> NIGHTS: !WST FIRST) PHOPE N WITH AREA CODE NIGHTS:yA E(LAST,FIRST) P ONE#WITH AREA CODE <br /> \J A A <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME dd CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Io intlicaie Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COOS PHONE N,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 ocicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAME STATE 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. 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 R AGENCY k FACILITY ID N B of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME 4 PHONE k WITH AREA CODE <br /> 2--- «lam u <br /> PERMIT NUMBER PERMIT APPROY41L DATE i PERIAT E%PIRA ION DATE <br /> LK <br /> E CENSUS'TRACI Y S PERVIS R-DIS;RICT CODE BUSINES YPLANFILED N0DATE FILEDES <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) / <br /> `i DATA PROCESSING COPY (�-J-'1 <br />