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STATE OF CALIFORI <br /> FORM AA': WATER RESOURCES CONTROL BOARD <br /> ZEZ F >y <br /> SITE UNDERGROUND STORAGE TANK PROGRAM f <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE z <br /> MARK ONLY 1 NEW PERMIT I <br /> ONE ITEM ❑3 RENEWAL PERMIT °�ArruxAMP <br /> 2 INTERIM PERMIT 5 CHANGE OF INFORMATION <br /> 4 AMENDED PERMIT E1 6 TEMPORARY SITE CLOSURE T PERMA CLOSED SITE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS- CA1 <br /> FAC(IL�DIy/SITE NAME (MUST BE COMPLETED) I_& <br /> `0 m Q.Y`G f&t r S CAflE OF ADDRESS INFORMATION d <br /> ADDRESS 4 /v <br /> °l 3 , NEAREYOSS�RZEI^PETCITY NAME e er !900 CODE ✓I8NoOmmk' N 0 P <br /> Pee-} ❑ PoM0NC <br /> O STATEAGDO0GAGDO <br /> STATE <br /> AGDO <br /> TYPE OF BUSINESS; 2 DISTRI6UTOR CA 5 BIT PHONE It.WITH AREA CODE <br /> ❑ 1 GAS STATION q PROCESSOR ✓Box if INDIAN EPA ID V `/ *6 3-99010 <br /> 3 FARM RESERVATION or ❑ <br /> 'RIMA TRUST LANDS <br /> EMERGENCY CONTACT PERSON P 4 of TANK's / <br /> DAYS: NAME(LA ST.FIRST) (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> THIS SITE <br /> PHONE#WITH AREACODEDAYS: NAME(LAST,FIRST) <br /> NIGHTS: E(LAS FIRST a- • /O� PHONE#WITH AREA CODE <br /> P ONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMAT INFORMATION &A- S/0/ PHONEk WITH AREA CODE <br /> NAME (MUST BE COMPLETED) <br /> ` .(.. CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS L <br /> ✓Box to intlic,le 0 PARTNERSHIP <br /> CITY NAME CORPORATION 0 LOCAL-AGENCY ❑ STATE-AGENCY <br /> TATE- GENC FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE <br /> PHONE 4,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME <br /> S %�p CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS lI <br /> -/Box to intlicata ❑ PARTNERSHIP <br /> EJ CORPORATION 0 LOCAL-AGENCY ❑ STATE AGENCY <br /> CITY NAME 0 INDIVIDUAL 0 FEDERAL-AGENCY <br /> COUNTY-AGENCY <br /> STATE ZIP CODE <br /> PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING INMCR ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> .n.PvisoA�sovr AGENCYR <br /> rS FACILITY IDR N Of TANKS of SITE <br /> CURRENT LOCAL AGENCY FACILITY ID R O O © HM <br /> APPROVED BY NAME <br /> PHONE R W17'N AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUI TRACTR <br /> © / SUPERV180 STRICT CODE <br /> BUSINESS PLAN FILED <br /> DATE FILED <br /> CMECKR PERMIT AMOUNT YES ❑ NO /� <br /> SU , <br /> gCHAgCE AMOUNT FEE CODE <br /> RECEIPT k Y. <br /> MUST BE ACCOMPANIED BY AT LEAST(1) <br /> ORM RMA OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A(3-(3-RR8M <br /> isDATA PROCESSING COPY 0 <br />