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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOAD r- <br /> yE! rNF <br /> W j <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH <br /> AA{{{C�H FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑Z INTERIM PERMIT ❑4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE #Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> w.' <br /> FACILITY/SITE NAME ( CARE OF ADDRESS INFORMATION <br /> AensTs <br /> i <br /> ADDRESS <br /> NEAREST CROSS STREET 2/11monOut ❑ VAAIMRSW ❑ VATE AGENCY <br /> / Ave. 13 COW MTION ElLOCLAGDO ❑ FEDERAL-AGEICt j <br /> ❑ INDMgIAi ❑ OMM-AGENCY I <br /> CITY NAME STATE ZIP CODE ITE PE N.WITH AREA CODE <br /> l CA 204H N 3(0 -32/ 1 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID NRESE - <br /> Ks <br /> E] I GASSTATION ❑3 FARM ❑5 OTHER TRUSTVLANDS ATION eF ❑ ATTH�SRE <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 N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> E <br /> MAILING or STREET ADDRESS ✓Box to indicale Cl PARTNERSHIP 11STATE-AGENCY <br /> DC <br /> ❑ CORPORATION El LOCAL-AGENCY ClFEDERAL-AGENCYUCS ❑ INDIVIDUAL ❑ COUNTY-AGENCY ' <br /> CITY NAME / \ STATE ZIP CODE PHONE N,WITH AREA CODE <br /> WV <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING or STREET ADDRESS ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Q CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑i IVIDUAL <br /> 11 COUNTY-AGENCY II <br /> CITY NAME STATE -ZIP C `�—'25DE -PHONEX,WITH AfiEA.CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> i <br /> CHECK.ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. A III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. j <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTIONS AGENCY# F ITY ID N M of TANKS E7 SITE <br /> i <br /> C ENT LOCAL AGENCY FACILITY ID N - APPROVE PHONE#WITH AREA CODE <br /> J9L C7 <br /> PERMIT PROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRRAACTT f SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> D �3. 30 E/.?0 YES NO �b <br /> GNECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONW UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-FIS) <br /> �'� DATA PROCESSING COPY\ <br />