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INSTRUCTIONS ;T TIa FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION,2711 OF 111`LE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS IONS ANIS SECTIONS 25256,25257,AND 252139 OF CHAP"T"ER
<br /> 63,DEVISION 20,CALIFORNIA HEALTH AND SAFETY COI)I:REQUIRE',OWNERS TO APPLY FOR AIN UST O P1 1;wNNCI IT'.
<br /> 1. One DORM",A"shall be compl,etcd for all NEW 1�LERIDIT CHANGE, or stay F,�C ILI S ISITF INFORMATION t#,1,�'GT"�.
<br /> - SUI3i4117 ONLY ON (1)T°C)RNI"A"for a Facility/Situ,regardless of the:number of ranks located at the site.
<br /> 3. This form should be completed by either the lti;t3amrr APPLICANT lir the LOCAL AGENCY UNDFI2C;ROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all:requested information,
<br /> 5, Use a hard point writing instrument,you arca making,3 copies,
<br /> 6. Tank owner must submie a facility plot plan to thelocal agency as part of the applichtiaara showing the location of the'°USTs with respect to'
<br /> buildings and landmarks(Section 2711(a)(g),dC RI,
<br /> 7, Tank owner must submit documentation showing compliance with state financial responsibility redquiremente to the l od agency as haft of the
<br /> application=for petroleum US"1"s[Section 2711(a)(1 1)t CCR).
<br /> 'TOP OF#Lt)RM"MARK ONLY Y ONE I`I"EM""
<br /> Mark ars.(7C)its the:box next to the hent that bust describes the reason the form is being completed.'
<br /> L FACILITY/SIT'a lNp'C)lt4"IA'11ON&AICD Ia,SS(mUST"BE£"£'mPL.F'L`ED)
<br /> 1. Record narnt,and address(physical location)of the underground tank(s),
<br /> NOTE: Address TAUS"Piave a validphysical,location including city,state,and zip code,
<br /> P.0) BOX l°a'C.rlb1BERS ARE NOT AC"C E ABLE
<br /> Include nears st crass street and nate of the operator.
<br /> 2. Phone number inust have an arca code. If,the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF ILLSI;NfiSS OWNERSHIP(ex,CORPORATION,INDI,t IDUAL etc.),
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5, If Fac.`slity/Situ is located within an Indian reservation or other Indian trust lands,check the b6x marked4`YES".
<br /> 6. Indicate the Nt;_41BE'R of TALKS at this SITE-
<br /> 7.
<br /> I ITs.7.Record the E,P,A.:I_l)#or write NONE"in the space provided,
<br /> II. 1'I�C)1'Elf"l'Y`i�tiT3#�lNl°aJaC�II'a'lI.()N�,1T3I)I�F:;1fS(1115`T'13I.C'(>N1I'I<l:TI1:I�)
<br /> Complete all items in this section,unless all items are the same as SECTION 1,If the carne,write."SAME AS SITE"across this section. fie sure
<br /> TILTANK A'.a4<OWNER INFORMATION& DKII.SS(-MUST BE CaC)MPLE"T D)
<br /> Complete all items in this section,tttkle55 all sterns are the starne as SECTION 1,If the Same,w6t£ "SAME,AS SITE"E"a rosi this section, Besaliu
<br /> to check`1 ANA OWNERS`I Y PE box,
<br /> IV,BOAlkl)OF F'QUALIZATION UST S"I OpACa[.FEE t1 `C)UN`I°NI BER(MUST BE twOMPLE,-IF,'D ST'iT:.1RTICLE 5,CHAVIT' 635,
<br /> DIVISION 2€,',£,AL.ITrC)iZ I3c 1H�.AL'l1f A S7 SAt"L':"'LY C(.>Z7kl.}
<br /> - dint r your-Board of l altualilaliort(1101:")UST sto asge fee accoura nutnber v,hich i5 rcquimd 1x for,your I nln.applic.as, n c a,a b,.4 roc=c.scd,
<br /> 1=cgi.t.tation ,a h tires Isf)c, w 111 en este that you Will rcc'eivc a quarterly s o ages-f c rett,rn in redia'taw ,.a,1,a._cu due on the
<br /> _. za;a.aLaertt;fzali,s. f,aa.,,.d,n}`u.ar..S<r., Iia..BOIL will Code leisutasexetnittrvrnpaay€rt,,th; y,ora,,uice sea. w_r:,v"„t_,. .._ .,i_t. �iza�tzr3�>na�t
<br /> ha c ata account nurnbcx s�ith thu BOE or if you have any questions regarding the Ceu o,cxem 3tions,atteaasr ,.til fl,c,B a.,al '916 322 90U-)otr,.vrite
<br /> to the BOE at the,lol[o"N ind addicss Boord of Equalization,FuelTaxcd)ivision,31.0,Box i 2t 79,Sacs a,fa.,ita;,CA 9
<br /> V. I'I';IIeC)I.l:t; I,CTS 1`FINAN Ir1L10I SPONSllt,Il_ITY(MUST FOR IIE'JR01 ::U'NI l'S'1' ()ti'LY,SEE,2EC,1.() h 2,711 E (S;t
<br /> OF-1111,1-21,C.IIAPI'Elt 16,CALIFORNIA O N'Ii1 CODEOF hl:O1,.,LA`l IC3NS")_...
<br /> Idwiti.y dic. ictilc.xz(s)owes by the sinner and/or opc;iator,in meeting the Federal and Statc,finaritial tc.°p,ons,hi[ay re�,i,t�.,�..aai .r S''3,: f 1>y°
<br /> any s GcfctA oa St,ate.,agency as well as nou pe,#role>a.ra L S"l`s are exempt from this tea uizcrncsat.
<br /> 1'T.LEGAL FIC'ATION AND BILLING ADDRESS
<br /> Check,ONE BOX for thl:aiddress that will be;used for I3C"ITH LE,'GAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER K 011 AI;'1"S3ORIZEI1) AND DATE TIll:laORNI AS INDICA T11 J�El,:I.,CTIONS-2711
<br /> (a)(13)OF"1 I.`LE 23'C'I IAI'?LR 16,C;AL.IVORNt_A CODE OF Idf OUL TIONS.)
<br /> INS`lI2UCT"ION 101 1111"LOCAL i's.t,C NClFS
<br /> The county an
<br /> jurisdiction tttana x r taro and esti be abtauaue by caillitag the Stoics 3c>arl{9'16}227-43M. ;tic: ai ,°u.la,ct.E,ap€xx
<br /> assigned by slat°#deal ag,,ncy;h000va,this number rrtttstbc numerical and catmot susttain sway alpraabeuc;al a1 the local agency pre°or`
<br /> the State Boal l to assign the facility number,please leave it bhink.
<br /> IT ISTHE RESPONSIBILITY 01"TITE I,f)C AI, AGENCY THAT INSPECTS'I11H, F''AC"ILITY`I'C) VERIFY 111E ACC.> �=t.0°Y OE`ill:
<br /> IN'FOIv'),IATION, T IIS AP,1'1,1(7,1 i-10,CANNOT BE PROCESSED 11°`I'III,BOE ACCrOf'N`S :NUNIMER.,S NOT FILLED IN, "11111;L C'Al,
<br /> AG11,"N& IS 1,.I. 'Caa4 113.,F;I t,)lt"I'ill3 C`t "fl3l°#:"4zC} ()F-Tllf "LOCAL Fac.,LN..,Y USE ONLY" TNI t;)WvTA"3'IC3N BOX AND FOR
<br /> FORWARDING'ONE}# i"kN A A'b;`L)ASSOCIATED FORM"B"(s) IClll,':FOLLOWING.'atlDRI,sSS, THELOCALAGENCY IZII()ULD
<br /> AND FORWARD THE,YELLOW COPIES TOTHP FOLLOWING ADDRESS.THE HE IIINK.COPY SHOULD,BE
<br /> t�l'1'tIlIiI3L3e""1llls'IAvCE is *1'R. a
<br /> STATE OF CALIFORNIA
<br /> 'STATE,WA�I`LR RESOURCES CONTROL BOARD
<br /> C/O S W.I;.E.P,S,
<br /> DATA PROCESSLNG CENTER
<br /> P.C),BOX 527
<br /> PARANMC U?sII T",CA 90723
<br /> 3:`b
<br /> FOR0120RI
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