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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM AAP: UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Aomrrhvir- ADDRESS NEAREST CROSS STREET ✓Sww MOV 0 PARiNEXgW 0 STATEAUE 0 COWOMTDN 0 LOCALJ,GENCY 0 FMEERAL AGEWN f" 0 INOMDUAL 0 CWNIVJGBIGY CITU NAME - STATE ZIP CODE SITE PHONE N,WITH AREA CODE L+AXJ�C'v CA TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ /PROCESSOR ✓Box if INDIAN EPA ID N If of TANK's ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANOS ur ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRBSS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I if. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY C�OUNTYY# JURISDICTION N AGENCY N FACILITY ID 17 N of TANKS at SITE v2to Y FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT EXPIRATION DATEPERMIT APPROVAL DATENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3. 2S� 3Zr- YES NOERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If Y: IsIsssssss THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 FORMA(9-2-89)