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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> FA,RK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F"A' <br /> ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> IV <br /> FACILITY/SITE NAME CARE OF DRESS INFORMATION <br /> CLtMI ISL Rl bTNramea <br /> ADDRESS /� I/.�/ NEAREST CRO STREET ✓sawiltecAe D PARTNERSHIP D STATE AGDO <br /> `] f r / ��0� El❑ InINi NDNIDW O ,1GENLY ❑ FEGERAL RGDIGY <br /> DDUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID a <br /> ESE❑ 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUST LATION or ANDS ❑ A of TAMP <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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 /> �} <br /> MAILING or STREET ADDRESS ✓Box to intlicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION# AGENCY B FACILITY ID N If of TANKS at SITE <br /> 3 Z <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMR NUMBER PERMIT APPROVAL DATE LL <br /> EXPIRATION <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE DATE F LE2 `�5 ❑ GCHEC a PERMIT AMOUNT SURCHARGEAMOUNT FEE B <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 /> FORMA(3-288) <br /> DATA PROCESSING COPY / <br />