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oT�.. <br /> STATE OF CALIFORNIX WATER RESOURCES CONTR6eBOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM 0 Z <br /> SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "Fox,e <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE III <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �J+ <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> rV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ss er <br /> ADDRESS NEAREST CROSS STREET ✓8orbidlsle C <br /> ✓r\"I A PAAP C STATE <br /> ❑ WPogeAT10N ❑ CCAGE11 FE3EWLL AGEN <br /> SJi CY63lu IN El INomouu El caNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> e C ccs CA <br /> I/Box If INDIAN EPA ID a <br /> NPEOF BUSINES 2DI TRIBUTOfl ❑ 4PROCESSOR RESERVATION or /� ��� Not TANK'N <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ /W N-l/A� AT THIS SITE o <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY <br /> Cl CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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 toindicale Cl PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> Cl INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ if. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 0 0 `V3 [3 101010 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ct SS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT ON CODE CENSUS TRAC N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED �fl� <br /> x YES NO /�� <br /> CHEC N 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 IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> ��\\ _C\� �aar DATA PROCESSING COPY ',� <br />