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STATE OF CALIFORNO WATER RESOURCES CONTRAOARD P zE """'r ,{ <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM = ° Z <br /> �. z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION d10 <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL D SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Do <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET COROAiIQN ❑0 LOGALAGEAp ❑ FEDEAA GAG NIX <br /> 2a 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> #RT To <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> EPA ID # <br /> TYPE OF BUSINESS: ❑ 2 OISTRIBIlfOR ❑ 4 PROCESSOR RESERVATION or ❑ AT THIS SITE /L <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TflUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Lo'ocL..te 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCYCl FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WII AHEA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box m md,cwe Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 DG,,_AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <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 /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m � � � o <br /> CURRENT LOOq LAGENCY FACILITY <br /> APPROVED BY NAME PHONE X WITH AREA CODE <br /> E <br /> PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESSPSN FILED NO ❑ DATE'FI� / <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX <br /> '/\ 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 ONLYl <br /> FORM A(3-2-88) 0 \ <br /> DATA PROCESSING COPY I <br />