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STATE OF CALIFORINA WATER RESOURCES CON L BOARD a <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM �a <br /> sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �44so P�'P <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S' <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FAC ITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS _ NEAREST CROSS STREET ✓Bw bntlkek ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION ❑ LOCAL ❑ HGEAAI AGENCY <br /> e r ❑ INGMGUAL ❑ CBUNiV#GENC1 <br /> CITY NAME STATE ZIP CODE SITE PHONE X.WITH AREA C DE <br /> s c, e4-v� CA 5 a D 5 ao ±& <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N N of TANK'N <br /> THER RESERVATION or F-]RESERVATION AT THIS SITE O <br /> ❑ 1 GASSTATION ❑ 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> v)l ; &&vI Cuhr,Q T ao9 GG- <br /> NIGHTS. NAME(LAST,FIRRS�STT)�� �_ ^ PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 15 a4_16'�'/ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> VY1Iles ?IrNISG.. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCY0 FEDERAL-A ENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 711 CODE PHONE N.WITH AREA CODE <br /> foc K�-�T � � G4 Sao 1 Cao9 `t&G-3F-3 <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRESS <br /> AD/DRR WK./ ✓Box to indcate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID B R of TANKS at SITE <br /> 1010OS-1C)10 <br /> CURRENT AL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> -p 4 a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE�STRACTN O SUPERVISOR-DISTRICT CODE BUSINESS PLAN YESFILED NO ❑ DATE F�� 1 <br /> CHECK N PERMIT AMOUNT_ SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> 1 FORMA(3-2-e13) • • <br /> c, `6 C( <br />