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e S�P`VO„ r~P <br /> STATE OF CALIFORNIA W*TER RESOURCES CONTROL BOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE j� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �<IIfOPN\P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE 7 <br /> ONE ITEM F2r2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE yP <br /> L <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> CARE OF DRESS INFORMATION <br /> FACILITY/SITE NAME "J,11'� <br /> ADDRESS NEARESTC OSS STREET ✓ Io iMicale ❑ PARTHE0.5NIP ❑ STATE-WOO (N� <br /> CORPORATION ❑ LOCAL-AGENCY 0 RBERAL�AGE10 <br /> Z[U �J ❑ INDIVIDUAL E COUNTY AGENCY <br /> STATE ZIP CODE ITE PH NEN,WITH AREA CODE <br /> CITY NAME I ©IE CA [J �0� 33y -Zffrb <br /> {NJr V <br /> TYPE BUSINESS: ❑2 DISTRIBUTOR ❑YROCESSOR ✓Bax it INDIAN EPA ID x M W TANKS <br /> RESERVATION or ❑ AT THIS SITE <br /> I GAS STATION F-13 FARM 5 OTHER TRUST LANDS All-A <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LA T,FIRST) PHONE p WITH AREA CODE DAYSN E(LAST,FIRST) PHO N WITH AREA CODE <br /> " Za 33y-z�s'a S 1(' <br /> NIGHTS: NA.-.(LAST, RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PH NE P WITH AREA CODE <br /> 141)i2ki�4J X76 30 -6Z.16 S A VA <br /> H. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF DDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓g0x loioBioate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ,x/(�xx n - i'=IORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> [/"1 (• ,! ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> . rA_ �"_` <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CAREOF RESS INFORMATION <br /> MAILING or TRE ADDRESS 'I ✓CORPORATION ULOCAL-AGENCY Brt 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME I STATE/4 <br /> ZIP COO PMO WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S Ir <br /> CHECK ONE(1)BOX 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY k FACILITY ID N N of TANKS at SITE <br /> a0 10 19' <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPRO D BY�ME PHONE N WITH AREA CODE <br /> 5 )t <br /> PERMITNN,UMMBER PERMIT P RO AL DATE PERMIT EXPIRATION DATE - <br /> / <br /> LOCATION CODE CENSUS <br /> ACT MSUPERVISOR-DISTRICT CODE BUSINESS PUN FILED <br /> C� 276 YES NO <br /> ONECKMZ ❑ DA F o(D�l(�p(/� <br /> L <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <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 /> FORM A(3-2-88) l\ <br /> v DATA PROCESSING COPY <br /> V <br />