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INSTRUCTIONS FOR COMPLETING "All
<br /> GENERAL INSTRUCTIONS:
<br /> S[.C:`I"ICy\2711 OFTITLE 23,CI I P T`II;R 16,CALIFORNIA CODE OPREGULATIONS TIONS AND SECTIONS 25286,25287,AND 1-5289 OFCHAPTER
<br /> 6.7„-DIVISION 20, ALIZ-UZ-N fA}IE A L-111 AND SAFETY CODIE REQU R F OWNL,:RS TO APPLY FOR AN UST OPE RATLNG PliR .
<br /> L C.htc FORM"A"shall be completed for all NEM PERMIT "MANGES or any T AC'ILI ` /SrFE INIrORMATZf N.,CHANGES.
<br /> 2. SUBMIT ONLY ONE(t)FORM„A"for a Facility/Site,regardless of the number of tanks located at thesine,
<br /> 3, `I"his form should be completed by either the PERMIT AN111C ANT or the LOCAL AGENCY UNDL RGROUND TANK INSPEC'IFOR..
<br /> 4. Please type or print clearly all requesied infeaznaatiors.
<br /> 5. Use a hard point writing;instrurraent,you are making 3 cnp:cs.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of she application showing the location of the LTS°r`s with aspect ilo
<br /> buildings and landmarks[Section 2711(a)(S)B C.C,RI, a
<br /> T Tank owner must submit documontation shorving co p,a,-lcje wim state financial reoponsibillity requirements to the local agency as Pan of the
<br /> - application for petrolcum 11"STs[Section 271,(a)(11),C"k`.1.
<br /> TOP OF ECAC' :" ARK ONLY C?h T t AT'
<br /> Mark an(N)in the b,ox next to the item that lct describes the reason theforan is being completed,
<br /> r. FAC�LITYJS:iI`F;LNF(JIZYIA"'f`Zf�i°C�.AL7I)R'] S(�'Ta�T' 3E Cf)Iv1pZaF"t"E�
<br /> 1. Record natne and address(Physical Location)of the orderground,tank(s).
<br /> NC TEl Address-NIL ST have a valid physical location including city,state,and zip code,
<br /> P.C3.BCI NUMBERS ARE NOT ACCLP'FABLE.
<br /> Include nearest crews street and name of the opera eon
<br /> 2. Phone number must h zvc air arca c<xi=c, If the,night nurnb r is the-same,write"SAME'in proper location.
<br /> 3. Check ck the,appropriate Ixnx for'TYPE YPi: €F B SINE SS L`t'a'F"IiRSHIP(ex.CORI'C?lZMI€)N,INDIVIDUAL,etc.).
<br /> 4: Check the appropriate boo,for TYPE C?T 4USENES .
<br /> 5. If F eiluvlSite is located within an Indian reservation of other Ind=air trust'lands,check the box marked"YES".
<br /> 6, Trait.abo the NL.ti BI. of"i'ANKS at this SITE
<br /> .
<br /> 7. Record the,I ,A,I'D 1 or write `NONE"in site space Clovide ,
<br /> H. PF3C)E'I..IZIAtIANL�i'C1Z4i €.) A1kxRIdSS€A1UTIliFCC7RIl'LIFIy)
<br /> Complete all liens in t:.a s section,unIcss;all€metas ere the same as SECTION 1,If the sarne,write"SAME AS FIE°"aac°rn s this section, Be sure
<br /> in check PROPERTY OWNFR HH,"TY PH€oke "
<br /> III.TANK OWNII.!Z 1NF(-)ZN'rs:'i'l0 c- ,1':zDRI" 4{Ik (.ST T3rl,t.t. M .AH 11D)
<br /> C;vt..rslUte aa,at.,arls i.a Llrr,.:c�tEc ra,�,nluasaL itearss are the ;,re as oF.C.I'C?N Y,d cue.samra,wra'c. :3 AA+ah.AS aI a`Ia aW.r�ss z} ,��c.ttr�. _sU sa.V
<br /> IN"V[SION 20,t .t1,1 °G.Z _ HEI I-ai;As,tr`ia,FE-l°i CODI—.)
<br /> _ L.....r you" 3.,...,c;f _..ars. ,I.C)> LS I fr..c r4coFkrt its"a„i3 ;w-h ,A ;rc;,;,r.tea lx:foyourpm,nm,
<br /> ia_ ':-« L�.,.�'�E.'will_ sE�s�i �..,�_ti:.Y;` ��r7,�r1 "_S-.s�€¢v
<br /> r� '
<br /> b.tV,a;t ar: ,.I°at a,aarr k_t V,ob tl,,�B4O1 ,rll,,vo,l , a;.y t,.atanrrc 3cgaldlug,,r”ic<,-ot cr..,i,tta aa.,plluas, , ul BQII
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<br /> t<r_htids€iL,:t.I,. E3;>,td„af ,F-ucllaxus D,c,a-;ar:9]r,€ .its>x€, .2z;'?, CA M
<br /> ' <u .- �=a.
<br /> srYL �S ' C:�� 'rEI �PEI,.t >1 � —ST'sCNLY,V }"iLOx. l ,lg( s, ,, t �i ,* `;'C �s� �.le.
<br /> C-)ic2tr :;:'3,Cll.+l >i. �.l;(:Alt?xh [.iC:� =,€)C lt,GLl LATIONS,)
<br /> ld( t. tru I:; t„” 3v r r lnd c.=opr. /le,atl n cr l ing the rel l f,and r:,., lh;,In,ci A, .,? �, ,,..4'rc.... . �.
<br /> arae r Cd,A,v s I.a_e"yv a y als n,:L as"on dein”" a m 1,Sa are cxrnnfa from this vlggtm..n eat.
<br /> CWCc9`''
<br /> lCI iSt1,k,efl
<br /> 'PCI.,..:lca; ,.,I.rtt a " _ Ica"??for H ITiGAL,AND
<br /> TANK 0WNE.RORAt,'!1'I=s.,?, e?(.:3RLIRr.SENTATtVI:MUISTSK3NA?b;all)a1.TT'll_.,FORMASEN'l.? ".s.':lFIDl
<br /> i>z,
<br /> (a)(1.3)OJl l(a LF 21 CI L1,111 Vlt 16,CALII OIi NIA MIX f).'R!lta'1'L,A'I10",'S.I
<br /> The courtiA a,.a..6sv,(t,z.naa€r0xa rs arc r„ e`tl and can be obtarner3 by€arll"g th S-Ia o f Turd,It 16�227 1== s Th-fa".t?t iris r`<"t r,a lv l-,
<br /> a.sigredby loc �<, cv_a,this s umb r anust be numerical az d cannot t contain.aoy, 1"t.,,r z x ">car.a l,r�;F ray
<br /> the State BoArdto a:: gn t.hc.I y number,please leave it.blank.
<br /> IT Is fill. Rl1 SPO NSIIIMIIA Y C:31t':HFI i_t)CAI. ;AC I;_N Y"t"II;?"l I v5'a.C`l:S THE, FACILITY L I`>'Y'1 CI t,, IUV x "fHl; ,LC C.t ,AC 4F Is TITE
<br /> Ir4(°{III_AfA.tON, "I HI;.!'tPP IC A'11 l:';€ A tieer:J"a BL PROC:FI`lSED IF THE BOF r1t"C0U 4 ;st; lBl,1 b IS NOT FILLED IN, 8:.LOC
<br /> AGENCY Y I`s s"a°:`>;C3NSHi I, ,OR"Llil C"stA;PL 1 0N, OF THE "LOCAL AGENCY USF.' ONLY" INIrC,€ IMA a.IC 3A" =30 .ANIIa FOR
<br /> I'C)1Z1';;a RDi G ONE FORM"" .A' AND ASSOCIATED 1'OR—M"13"(s) TCS tiFL.FOLLt3WLNG ADDRESS, THE,LOCAL,AGEINCY SHOULD
<br /> RI,IA N`l HE, ORIGINALS AND FORWARDTHE HE YELLOW COPIES TO ME FOLLOWLNG ADDRESS,111E PINK COPY SHOULD BE
<br /> RETAINED BYTIHLiTANK OWINER.
<br /> STATE OF CALIFORNIA
<br /> .STA`hE L°ATLR RESOURCES CONTROL BOARD
<br /> C10 S,W.E.F.P.S,
<br /> DATA PROCESSING CENT
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3 93
<br /> FORmOR1
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