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h t. , a: 90.E IT <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BORD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM = " a Z <br /> SITE FACILI Y/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ""$FOR P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE N <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> `THE 1�4P.N.E-R CaM �-+.)• <br /> NEAREST CROSS STREET IoiIRCBIB ❑ PARTNERSHIP D STATE AGENCY <br /> ADDRESS A� CORMTION 0 LOCAL-AGENOf 13FEO AILAGDILY <br /> 11 f4jAr ,J 0 INpVIWAL 0 COUn-AGENCY <br /> STATE ZIP ODE SITE PHONE 11,WITH AREA CODE <br /> CITU NAME <br /> S-7,0&kG to tj CA 6 <br /> TYPE OF BUSWESs: ❑ 2 DISTRIBUTOR ❑ EPA ID p 4 PROCESSOR E ERVATION or - lye #of HIS SI <br /> aN <br /> F-] 1 GAS STATION F-13 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE q WITH AREA CODE <br /> S <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,7A G( S <br /> MAILING or STREET ADDRESS ✓ oz to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> Ct <br /> MAILING or STREET ADDRESS oz to indicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 'I^ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L I v l it. ❑ Ill. ❑ <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 h SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 3 � 00 / 020 000 <br /> CURRENT LOCAL AOSN CY FACILITY ID# APPROVED BYLN&ME PHONE#WITH AREA CODE <br /> L6,A­k N a1 w <br /> PERMIT NUMBER PERMIT APPROVAL DATE/ <br /> /D-"✓ PERMIT EXPIRATI NDATE <br /> L <br /> ION CODE CENSUS TRACT# SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILEDO Z ? �� y7�lYES NO <br /> # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) <br /> • DATA PROCESSING COPY • <br />