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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INTRU TIONS;
<br /> SEC I`ION 2711 OF TITLE23,CHAPTER,16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 2.5289 OF CFIAPT I
<br /> 6.7,DIVISION 20,CALIFrOW A HEALTH AND SAFETY CODI-,RE'QUIRE OWNERS TO APPLY FOR,AN UST OPER.A`2INGr PER;
<br /> 1. One I"C31$M"A"shall be completed for a'1 NEW PF:RMIT?:H A G S or any FACILITY/SITE LNFO NIATION C°lltUNGE&
<br /> 2. SUBMITONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of banks located at the site.
<br /> 3. This form should be cotuptcted by either the PERS✓11T APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSF'Ec1"O .
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point write inst'r'urracint;�t�a"are sxa�kixi�2 e ies,
<br /> 6. Tank owner must submit a facility plot plan to slat lata:gags ncy as part of the application showing the location of&a VISTs with aspect 3a
<br /> buildings and landintrls[Sect ion 2711(a)(8) 'j
<br /> ,
<br /> 7. Tank owner:utast submit docutnr tatiU s sh 3v it g e&rttpl>aneo °ith state financial responsibility requirements ict the local agency as part c f the
<br /> application for petrol a rr US`Is[Section 1,71.1"(a)(Ij), CRF
<br /> s s
<br /> TOP OF FORM,"MARK ONLY ONE ITE�AI"
<br /> Mark an(X)in the bras neat to the item that best describes the reason the farm is being completed,
<br /> I. FACILITY/SITE INFORMATION&ADDRESS(NI USTBE COMPLETE,D)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE.Address MUST have a valid phy sicai location including city,state,and zip code
<br /> P.O.BOX NI,IMBERS ARE NOT ACCEPT ABLE.
<br /> Include nearest truss street and tonne of the operator.
<br /> 2. Phone number catna have;an area code, If the night number is the same,write;"SAME,"in proper location,
<br /> 3. Check the appropriate K)x forTYPE YPE OF BUSINESS OWNERSHIP(ex,CORPORATION,,INDIVIDUAL,etc.),.
<br /> 4. Check the appropriate be)x for TYPE:OF BUSCa°SI SS.
<br /> S. If I acility"fSitc is located d within art Indian reservation or other Indian trtelst lands,check the box marked"ASS*%
<br /> 6. Indicate the NUMBER of FAINKS at this SITE.
<br /> 7. Raord the.ERAr'119 0 or write"NON:-in tfre space provided.
<br /> Il. PROI'hI�l'Y�O)VNER I.Nl,'SRM A'F"ION&AI?I)FLIiSS(MI JST I3k ;€ MPT E E ) :
<br /> complete all items to this section,unless all items are the carne as SIiCI SON I;If the same,write"SAME.AS SH* ae; ss this sccticn.,,13e sure
<br /> to check PROPERTY OWNERSHIP IP"l Y 1'E N,as,
<br /> III.TANK OWNER INFORMAT ION&ADDRESS Qo1UST BE COMPLETED)
<br /> C:ornplete all items its this section,sinless call items are the same as SECTIO I,If the same,write"SAME AS SITE' across this section. Re suet° a
<br /> �cr;I'A°C?C�AA'.L`I?`i'1'Ylaliia<rx-
<br /> IA'.WARD 01 F.,Q t.:1t_a i?A i 10 USS S .A
<br /> FGRGE F'F'F ACC OU `t T U MBE—R,(MUST BE C:ONIPLL"I`ED.SEE AR"1"ICI E 5,C IIAI'"I 1',9-63
<br /> {
<br /> :fit' �a(l -0,C"tAZ:if°ft?L`il.rl HEALTH AND SAFETY CODE.)
<br /> J a: r you,lli:ard of l.y;aaFtz a,> (EC?l.l L ST st r age fee.acrcount number xh ch is Tequamd'before yciur p -6t ap [�".,,tt< u�Ise;rr:.r c.,(�d,
<br /> R gkilation. ills 111. 1401"vv"L r e t,aY you-'sill feceive,a quarterly stmage fee return in rglo ri g,All ;." X��(d t l:-; r�-r ftrE L c .s a>n`�tom:
<br /> i;,5c .r a :*. `the BOE wu1 cc,de per'-sag exempt,f c;esr paying the sto+a;c ice;s,r lcitums wdl,.�i 1,c. „ca, s`t aoo d6 rico
<br /> s v,�,an ac c ,..n nt m€ur%6;h lhlw B01,or if Y au I avu any questions r.gasuirfrthe;cxe pl, so,.all 0,e-B01"ger 1a a z„; .;a + 6i.r,°re>e
<br /> , . �._
<br /> to aic.?130E at the ieJ,k.>v-sad.ati,li>,ss i;A.a�F of hcF aat�r„rtaezn,r°ue1 ;ax��Z3ivssaun,IW,};L�`?.+mss,"J,`r..�r4.zt,.P c>;C:.1 t)-1l,I}.("N4,
<br /> .
<br /> f r.
<br /> V. '{l?'E:"Fltf I I1.1.;`11rrL, `qqI iri<s.3 .aAt,,*I.S.('55C3 4a'f:Il..I`t]Y(4Ni"'IS a'�i.$a3I°;,G'C"?nt�,tP COMPLETED FOR PEI Sit:il.E 11 1.S"i`.s ON LY,
<br /> OF E I I,E 23,t €I.Xf}i ER 11,t..1�A1 11€_�Il',. IA CODE"OF RIaG LA S:lONS.j
<br /> lc.t�tiiy tt,c,as.U,I” i, ,e us;%'by the ownsor anclor opciator,on anlceimis the Fcacral and At.:t,firkancial acsporls s.,t.ity , ..,.ra,by
<br /> ;any hedcra'orsSt;azt agency as well as non u.n tiS'Is are e ecelfa froth this r It.tin,arn rr
<br /> YI-LF'GAL N011 ICATION<AND B11.11'G ADDRESS
<br /> Check ONI:,BOIX for th.,adotess[,flat will be used for BOTH LE(3AL AND
<br /> TANK OWNER,OR Ah'l'Flt)1OZED REPRFI:SE NT"ATIVE-1mu.sT SIGNAND DATE I[1d,?QKM AS INDK-A`%�l t, P;F' ,SD"',110 S 2"`11
<br /> (a)(13)01`1111,1i 21 C HAIP'll FR.16,CALIFOR-SIA CODE OF RRIGULATIONS.1
<br /> FINS`R CITON FOR TFT?.WC AL,AGENCIES
<br /> The county an Jurisdiction nuinl>ets arc.predetermired and can be obtained by calling the"stats;Board(()16)22'7-X1303. It_e brat nbosr noisy be
<br /> assigned by the local ag;-ncy,Ssr o ver,this number utust be numerical and cannot contain any a,r h,ahrucal charactcrs. If the local agcncy"rinAcTs
<br /> the Statel'isoard to assign the faci:ity number,please leave it blank.
<br /> IT IS fills RESPONSIBILITY OFTHE LOCAL AGENCY'I'll t'I'INS PEC TS '11II:F'ACIL 1 Y TO VERIFY °I"IIb AC CILTR AC"t' OF"PlEt
<br /> LNFOR`IA` ION, 'I'IiIS AI'i'LIC.A r.l(.)N CAIti:\'OT BE.PROC:I3SSED FI°TI ILS BO ACCOU,\I tiL Y'2lllils IS 1N'0"I`ItFf..L,t"D I". 'I'Iif,,IMAL
<br /> AGENCY IS REISPONSIBLI FOR THE COMI'LL,riOlq OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR.
<br /> F ORW ARI)s.NC,,OSI,i ORM'*A"AND ASSOCIATED DORM-"B"(s)TO THE FOLLOWING ADDRESS. THE E LOC..AL AGSENCY,SHOW D .
<br /> RETAIN'1111.7 ORIGI CAI S AND FORWARD IIE`YELLOW COPIES TO THE FOLLOWING ADDREgS:IVE PINK COPS IL7IILD'iE
<br /> RETAINED B Y'I FII:TAINK OWNER.
<br /> STATE"L WATER RESOURCES CONTROL.BOARD
<br /> DATA PRC?CES;SL G CENTER
<br /> P.O� BOX 527
<br /> PARAMOUNT,CA 90723
<br /> u93 F '_ t
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