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STATE Of CALIFO,RN WATER RESOURCES CONTRBOARD <br /> FORM AA,. o- s <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! " <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 9<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) I C) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �� <br /> fN�SM A�/ M �grv)�G <br /> ADDRESS., w NEAREST CROSS � . ✓Roxlaiwui ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> 3 Q /�� y,/O ' ❑ WRPOROON ❑ LOCAL AGENCY ❑ FE ER4L-AGENGY <br /> CITU NAME ' i1 -v B-vcviGUAL ❑ COUNN AGENCY co <br /> STATE ZI COO -16 <br /> ^E SIY%P�NE#,WITH�REA COD <br /> TYPE OF BUSINESS: ❑ 2 DIS UTOfl ❑ 4 PROCESSOR ✓Box if INDIAN EPA IDA ,�/ ddVV `:GJ'�/' 3 <br /> ❑ 1 GAS STATION FARM ❑5 OTHER TRUSTYATION LANDS O ❑ WOti� AT THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME( ST.FIRST) PHONE#WITH AREA CODE <br /> ltit ti`s - 20 <br /> NIGHTS: NAME(LAST.FIRST) PHONV#WITH AREA CODE NIGHTS: NAME(LAST,F)RST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> I. ) <br /> MAILING or STREET ADDRESS r ✓Box to i tdicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> CORPORATt/ El INDIVIDUAL FI <br /> FEDERAL-AGENCY <br /> FI COUNTY AG NCV ❑ <br /> CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 'SA,r'La✓ 14—'� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOR 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# If of TANKS at SITE <br /> I olo 1 11 t cdol v <br /> CURRENT LOCAL AGENCY FACILITY ID If APP7Q7 PHONE k WITH AREA CODE <br /> of 7 S rr <br /> PERMIT NUMBER PERMIT APPROVRL D/1 PERMIT (ATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C) YES ❑ NO ❑ <br /> CHEC # 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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-24BB) • • <br /> DATA PROCESSING COPY <br />