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STATE OF CALIFORNM WATER RESOURCES CONTRdrlBOARD FORM AAI: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z 10 COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT L CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION J KL f% ADDRESS NEAREST CROSS STREET ✓Fork nOirak 1-1 PARMENSIIP 13 GiATEAGENC/ Cl DNPOBAnON O LOCAL-AGENCY 0 FEIgB<L-AGENCY 1-1IWMDUAL 0 CCUPYAGENCY CITY NAME STATE ZIP CODE SITE PHONE B.WITH AREA CODE CA ��33 d� 7 -(IYW TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PNGMR ✓Box it INDIAN EPA ID N - RESERVATION or - Xo1 TANK'a c=XEly ❑ 1 GAS STATION F73 FARM OTHER TRUST LANDS ❑ ATTHISSITE G EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N E(LAST,FIgST) PHONE#WITH AREA CODE DAYS. NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FI ) 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 /4y MAILING or ST ET ADDRESS ✓B Oicate 0 PARTNERSHIP 0 STATE-AGENCY CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY O �✓� ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �3 MAILING or STREET ADDRESS JBox to lreft.te 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ErIII. ❑ 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 W JURISDICTION R AGENCY N FACILITY ID M N o1 TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L ON C DE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �3. � 1�1 YES NO ❑ �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY FORMA(3-2-88) - )tDra DATA PROCESSING COPY now