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STATE OF CALIFORNIA WATER RESOURCES CONTROLIDARD <br /> ,SEII a OIC 1Hf <br /> FORM AA': t. <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE ,> <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEMEl ❑ T PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> 3 NEAREST CROSS STREET ✓R IRWN 0 PARTNERSHIP 0 STATE AGENCY <br /> -1� -�(C I_ ❑ CORPORATION ❑ U)C4 AGENCY ❑ FEDERALAGENCYCITU NAME �1 "` 0 INDMOUAL 0 CODNiY-AGENp <br /> I tx STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> 1 CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ ROCESSOR ✓ <br /> ❑ Baz if INDIAN EPA ID p <br /> ❑ I GAS STATION ❑ 3 FARM �THER RESERVATION or ❑ _ IF of TANKL I <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) A <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> nn PHONE p WITH AREA CODE <br /> NIGHTS: N ME(LAST,FIRSTI PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> c <br /> MAILING r STREET ADORE <br /> ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME Je' 0 INDIVIDUAL DCOUNTY-AGENCY <br /> STATE 21P CODE PHONE k,WITH AREA CODE <br /> � 3316 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> e4dfr— V- CARE OF ADDRESS INFORMATION <br /> MAILING OrtSTREET ADDRESS Box Lo intlicale CIPARTNERSHIP <br /> �� CPAP+"' 0 CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> V 0 INDIVIDUAL ❑ COUNTY- 0 FEDERAL-AGENCY <br /> CITY AGENCY <br /> STATE ZIP CODE PHONE 9,WITH AREA CODE <br /> C N Com 256 U <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# fII AGENCY M 1II� FACILITY ID <br /> K D <br /> I � % fc� / Mol TANKS At SITE <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME <br /> Rc �r PHONE N WITH AREA CODE <br /> C� PERMIT NUMBER L_ OC "� PERMIT APPROVAL DATE PEpMIT EXPIRATION DATE <br /> v LOCATION CODE NSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> 3z S YES NO DATE FILED <br />\ CHEC N IT AMOUNT o SURCHARGE AMOUNT FEE CODE NO <br /> N ❑ n <br /> BY: <br /> THIS FORM MUST BE ACCOMPANI (1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> f\. FORMA(3-2-66) <br />�j <br /> "c <br />