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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM AAI UNDERGROUND STORAGE TANK PROGRAM <br /> SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> SMS <br /> ADDRESS ��� /�'�/ NEAREST CROSS STREET <br /> r1 ✓BaWWM ❑ PARTNERSHIP Cl STATE AGENCY <br /> UO (/" 0 WWORA¶ON 0 LOLL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ CaPMAGENC( <br /> CITY NAME STATE ZIP CODE / SITE PHONE N,WITH AREA CODE <br /> CA 9f2o& <br /> TYPE OF BUSINESS: ❑ y IBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID It <br /> RESERVATION or X of TANK'F <br /> ❑ I GAS STATION [01 FARM ❑ 5OTHER 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME �,r� CARE OF ADDRESS INFORMATION <br /> 0,>E.A vv f <br /> MAILING or STREET ADDRESS /I ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11QPi O CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �//1 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE <br /> M �o �— /_ ' <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toiedicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-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: I. ❑ it. 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 X JURISDICTION X AGENCY X FACILITY ID X X of TANKS BI SITE <br /> M = = 1010 l 7 000 � <br /> CURRENT LOCAL AGENCY FACILITYI X APPROVED BY NAME PHONE X WITH AREA CODE <br /> JI�eL°�L%(o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATIONRODE CENSUS TRACT N SUPERVISOWDISTRICTCODE BUSINESS PLAN FILED DATE FILED p <br /> YES ❑ NO ❑ t`7 /��O <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: <br /> M 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 /> SB) <br /> �' DATA PROCESSING COPY "� <br />