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or <br /> STATE OF CALIFORN WATER RESOURCES CONTR L BOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM <br /> m.• <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ,P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑' 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ ,� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> n CARE OF ADDRESS INFORMATION <br /> FACILI SITE NAM _ S n <br /> ADDRESS NEAREST CROSS STREET ✓COWRxaN Cl LOX PARTNERSHIP Cl FEDERAL <br /> ENCY <br /> ADEN <br /> r� /1 C Cl GgP00.AlIDN ❑ LOGLLAGENLY ❑ FEDEPAI AGENCY <br /> -�(1 I A SQGY-G rT v ^-4� LG IGv C� L-A ❑ INDIVIDUAL ❑ 0DAMAGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Lc) CA >�`� .209 3(0`L <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box,f INDIAN EPA ID N #of TANK'# <br /> RESERVATION or AT THIS SITE <br /> F-1[NIGHTS: <br /> GAS STATION F-1 3 FARM 5 OTHER TRUST LANDS ❑ <br /> RGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box tomd,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CIN NAME <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRIESB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ ILL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY k FACILITY ID N If of TANKS AI SITE <br /> 39 �] = o 3 o o <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> ACK �C� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSSUSyyTRA�C71T NN SUPERVISOR-DISTRICT CODE BUSINESS PLAN F❑ ILED El ND ❑ DATE FILED <br /> Oa T Lv L41 9 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 1 FORMA(3-2-BB) . <br /> J <br />