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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W FORM AA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 14 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFOR ATION ADDRESS NEAREST CROSS S ET ✓AP[b YbfY! 0 PARTNERSHIP D STATE-AGENCY E 0 CONGRAGON D LOCAL-AGENCY 0 FB)EBALAGENGY 173 {/ AL D WUNIY-AGBIC/ CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S fiac�-kw CA qszOS TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N flESERVATION or N of TANK's ❑ 1 GAS STATION �3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(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 II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION N MAILING or STREET ADDRESS V`Box to indicate 0 PARTNERSHIP D STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) SII NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE I IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. LZ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID N N of TANKS at SITE 3� D 10a_ 10 1 ? 161 10101010 CURRENT LOCAL;;NCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Ll CENSUSTMCTN BUPERWSOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23.SO L/it YES ❑ No ❑ � If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 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. FORM A(3-2-&S) DATA PROCESSING COPY --.