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STATE OF CALIFORNIA WATER RESOURCES CONTROPBOARD <br /> FORM `l4': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r <br /> q COMPLETE THIS FORM FOR EACH FACILITY/SITE °qL,K©'`" <br /> MARK ONLY E21 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT Ej 6 TEMPORARY S)TE CLOSURE 1 IV <br /> f 00 <br /> I. FACILITY/SITE INFORMATION 8, ADDRESS- (MUST BE COMPLETED) 0 <br /> FACILITYgSITE NAME l CARE OF ADDRESS INFORMATION <br /> V <br /> ADDRESS <br /> NEAREST CROSS STREET ✓50K 10 Mirale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El <br /> CORPO <br /> CITY NAME <br /> ❑ N6 pALIGN ❑ COUNTY-AGENCY <br /> El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> STATE 7iP CODE SITE PHONE It,WITH AREA CODE <br /> TYPE OF BUSINESS: �2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID #A <br /> I GASSTATION 0 3 FARM 5 OTHER TRUSRESETVLANDS ATION or #of TANKI <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AHEA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 1:1COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ili. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL F] COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE#,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: 1. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> .1, 3 <br /> / <br /> CURRENT LOCAL/AGENCY FACILITY 10# APPROVED B NAM / PHONE#WITH AREA CODE <br /> ff[f i t7 �ibl/ <br /> PERMIT NUMBER PERMIT APP/ROYAL DATE ERMIT EXPIRA ON DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES L_I NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORA!MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A(3-2-88) <br /> DATA PROCESSING COPY <br />