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STATE OF CALIFORNIA WATER RESOURCES • " °`^ • CONTROL BOARD z`'•°'`T^}E FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oe�`" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CL E I-.a ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) O 00 FACILITY/SITE NAMC� CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓g00mii PARTNERSHIP ❑ STATE AGENCY !�- O A'i �h / / f. ' ❑ ION ❑ LOC4L-AGENCY ❑ FEDERAL AGENCY liLlf DMDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S't lc CA cz TYPE OF BUSINESS: ❑ 2 DI UIOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID N AT THIS SITE 1 GASSTATION FARM RESERVATION or - / ❑ E] 5 OTHER TRUST LANDS ❑ (�(. !(_._-- EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS vp / Box to scale Cl PARTNERSHIP ❑ STATE-AGENCY SO/ �Ia/ /LGu iG�. ❑ C ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY l� DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME e y•y�� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to i - e ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ ORPTION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY NDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ It. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY k FACILITY IDN eq a of TANKS at SITE Go U CURRENT LOCAL AGENCY FACT rVjD# �� APPROVED BY NAME PHONE Ar WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED J 3 a 3 YES NO E, ! CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: WTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88) DATA PROCESSING COPY