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•COOU• ; 00 <br /> STATE OFCALIFOTiWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> ro <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE q 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBAR CIINAME NAME OF OPEERATOR�I4 Kong, <br /> ADDTq NEACWSS PARCEL <br /> Nbnfe iablo 0,11JYI� J <br /> -y30-02-5 <br /> CITY# M ���h� ST TE LODE <br /> P 5ZO3 SITE PHONE#WITH AREA C <br /> CA <br /> T.1 Box O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY f� COUNTY-AGENCY ED STATE AGENCY l� FEDERAL-AGENCY <br /> DISTRI <br /> TS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ gESEIF RVATDION #OF TANKS AT SITE E.P.A I.D.0(ap!lanali <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS l <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•aptlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> ] <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRS n PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 1 g (� J LI vn CARE OF ADDRESS INFORMATION <br /> MAILING9SR TADDRESS e`J I-(/� ✓ hmbindica 0INDIVIDUAL l3 LOCAL-AGENCY (]STATE-AGENCY <br /> m,(J� _ (J(Q.IUI.L� �CORPORATION PARTNERSHIP = COUNTVAGENCV FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ccGGllftn Coq g5203 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNERQQ � CARE OF ADDRESSINFORMATION <br /> v <br /> MAILING OR STREET ADDRESS INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> l�CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -1 I I 1—= <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless ox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ijx II.❑ III.❑ <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) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUh^Y# JURISDICTION# FFA T # <br /> L d a <br /> LOCATION CODE�ITIONAL CENSUS TRACT yI,-nONAL SUPVISOR-DISTRICT CODE .OP77OWL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FOR=3A-R2 <br /> FORM A(9-90) <br /> Uv <br />