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STATE OF CALIFORNIA — WATER RESOURCES CONTROL SeARD s\ <br /> FORM `AA: UNDERGROUND STORAGE TANK PROGRAM =�°� a� z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° �c <br /> C/' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> v <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 CO <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) (L� <br /> FACILITY/SITE NAME ,BAPE OF ADDRESS INFORMATION <br /> ADDRESS �0 - /I NEAREST CROSS STREET ✓BmbnEnb ❑ FARMEA911P ❑ SIATEAGDO <br /> GD <br /> IL�/Ir7V ❑ WFPOMTON ❑ LOGLL AC¢NC! ❑ FEE I)�Wd-AGDILY <br /> Cl INDNIDUAL D COUNTY AGENCY <br /> CITY NAME $TATE ZIP COQ / SITE l O�I EN.WITH AREA CODE <br /> CA // <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIA EPA ID N M of TANK'N <br /> ❑ ❑ 5 OTHER TRUSTVLANOS r ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST] - - -PHOONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> % N S: NAME(HST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11, � <br /> 11. OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STRI ETA ESS ✓Box to lndicaM ❑ PARTNERSHIP D STATE-AGENCY <br /> O 0 D CORPORATIGN D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL I D COUNTY-AGENCY <br /> CITU ME �A STATE P CODE �� PHONE N.WITH AREA CODE <br /> 1 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFAD ESS INFORMATION <br /> MAILING or STREET ADDRESS --- — ✓Box toinoicate D PARTNERSHIP OSTATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRI kANoIcnRRF(-T. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY R FACILITY ID k If of TANKS at SITE <br /> [lHl [�] I I I z Iy= I I I I l <br /> CURRENT LOCAL AGENCY CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CI( YES NO <br /> CHECK* 1 1 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 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. I ^ <br /> FORM <br /> �J�2��. ✓J <br /> DATA PROCESSING COPY (�(y <br />