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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '" "` FORM 'AA: UNDERGROUND STORAGE TANK PROGRAM „o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , . COMPLETE THIS FORM FOR EAC FACILITY/SITE `'��Foa"`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION NleoL04f- s ADDRESS NEAREST CROSS STREET ✓Bmbbtiola 0 PA NMW 0 STATE AGDO 23 c ❑ axeauTwr� ❑ iocu,0BA,Y ❑ PEOEau.wca�r ❑ IlmmoUAL 0 CUM AGENC( CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE Joe CA TYPE OFBU NESS 2DISTRIBUTOR (PROCESSOR ✓Box 4INDIAN EPA IDM ❑ ❑ ❑ TRUST LANDS RESERVATION w ❑ AT TH0 of IS SITE 1 GAS STATION 3 FARM 5 OTHEfl EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inbiCala 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME $TATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION b ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to in6iwle ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR MOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID K If of TANKS at SITE 3 = = 1 1 12- z 3 CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE Icocz: PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO `� CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F SY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERYR FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FO -2-88)