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INST J .: tl N FOR. LY , '.a . SGT d.. "Alf tt
<br /> GENERAL INSTRUCTIONS:
<br /> SEC'11ON 2711 C)I"I'1'i'isi: 3,.C.E..1P"t`I it ICT,CALIFORNIA CODE,OF R2FG LATIONS AND SECTIONS 25286,252k7,;ANI)25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE E REtQUIREE OWNERS TO APPLY FOR AN L S`I'C)I'TERAT1'N'G r s`RIv rr.
<br /> 1. C)ne la(')ItM "A"shall be completed for all N IiW P ER.'Ni"F"CHANGES or any FACI !SITE:INFORMATION CHANGE&
<br /> 1 SIMMIT€ NLY ON (1)f-'ORNt`A"for a Facility/Site,regardless of the number PrP tanks located at the site.
<br /> 3. This.ono should be completed by either the I'tsi2:Nf1"T APPLIC AaNT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all rt qucsteai infotrmnion.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner roust submit a facility plot plats to the local agency as part of the application showing the location-of"the U°STs with•respect to
<br /> buildings and landmarks(Section 2711 (;a)(g),C CRI.
<br /> T Tank owner must submit documentation showing compliance withh state financial responsibility mquirements to the local agency:as part of the
<br /> app kation for petroleum USTs[Section 2711 (a)(3 1),CCRJ]
<br /> TOP OF FORM "MARK ONLY ONE ITEM"
<br /> IEM
<br /> Mark,an(X)in the box next to the item that N,.q ricsc€apes the reason the form is being completed.
<br /> 1. FAC:ILI Y/SI"I'F,U FL.3Tilf:'TION ss AJ)D I FSS(NIl ST slF t"f)MPL E'PD)
<br /> 1. Record nanne and address(physical loc:aiiori)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,slid zip coder
<br /> P.C),BOX:lCI?Yi(3FII.S AREN(')'1 ACC'TEE'"J'ABhl.
<br /> TraclUde nearest crass street and naane.of the operator.
<br /> 2. Phone number snnust hose art area code, .If the night number is the same,write"SAME"in proper location,
<br /> 3. Check this appropriate i.,ox for TyPF OF BUSINESS OWNERSHIP(cx,,CORPORATION,INDIVIDUAL,etc.). .
<br /> 4. Chock the appropriate box for TYPE OF Il1,,SfN ESS.
<br /> 5. If Fa clay/`rte is lvrcated within an Indian reservation or other Indian),rust lands,check the box marked"YES".
<br /> fi. Indicate the 1tit;I'V9I3FR of TANKS at this SITE,,
<br /> T Record the h,1v.A.:ID#car write NONE-in the space provided,
<br /> Complete atl items in this,section,i nl",all items are the sante as S1TC'110 -1;I4 the same,write"SAME AS SITE"=acso<s this 5 ccz<at. Re satire
<br /> to check PROPFRfY C.kWNI RS111f Ylll<box,
<br /> UL TANK OWNER I".4FC)IIMA`a"IO &ADD!-'FSS(MUST BEE CtJMPL E"IT D)
<br /> Complete all item,iin this sear>tt,ttnlCss al itaMts arc tete.shine as SI:C:TIO l;If the same,write"SAME.A4 SIDT"?I:"acroes this scslion, Ile sour;
<br /> to check TA s'K<)14'.!ERS TY1'i::Ixm,
<br /> IV,BOARD OF I QC'AI,d7A I`JON US I ST OPAGE l'E is.1G,COUIN"I' tiUMBE-It(MUST BE;Czt MP1,ti'i1.I1 Sl,iT'ARTIC11"s"C..HAIYl l-'R 6,75,-
<br /> DIVISION 20,CALIFORNIA IEC ALTJI AND S.'b1E.TYCODIa-.)
<br /> I3tatcr your Board of T-1'(JU alixa,ion(ItOl:i)'£UST a.ta:age sec accountnumber xhie'l2 is required before:your fx mit aI ldioation..a;n be procee,exi,
<br /> Itc pt;.t_ariora cvitta t'ae I>C)I,v":11 3,�t..w i taal you ssil;r,tcc;ive.a quart r]y storage fee rtasarr'ut reporting the SO,(Y,)6 fuer dkw,on dw,
<br /> tsa:nl e'r of geflons baso od in your<,`I.,'I}"e B )F.Will co&persons cx'npt from paying the storace fee so r tUarn 4'dl no;,be ,.,..i. Tf you do iraj
<br /> have an nu bsr v with rite,BOF or if you have any questions regarding the tcc or ex,trrthti0nS,I>IWS'-, ..ail the M a,.a€ 7: i _.'9O61 or,
<br /> ssiaca
<br /> to the BOE at the fotlox i:ng addic ss llo,rd of Lquat,:zation,Fuel`faxes Division,11.0.1`iox 942879,Sac.<rT cinto,CA 91,2J. t,, 3£32.
<br /> V. I'EI ROLI_„1�int l:tom C Ir4LR E` !'C}�Stl;Il.1,l'y(,y1t'S'T I3TwC'C)�11'Lf:11:T3T"f)I�l'IE" att)a,f:;iti l `1'a E3 1.�,:r"I�?t„a.,. <{aN,>2711 �shit
<br /> OF` FI L 23,C'H P i aER 16;C:AL,II£)IRNIA C.ODF.OF REGLU.A-I IONS,)
<br /> Idewily tht to..whWfsf used b its raceting tits lural and Suit,.fin aancial,>„aa.>.}s bi`.y l a.._e..."r,.t s t;,n..db""
<br /> any 1 cdcaad orstatcrigcnwy ss well as rias n pc lolcum L"S'S's aarc exettipt from this loquitcrnean,.
<br /> VE.I.EsC"s; t, SC)a"I1"i('1'E`I4?ti
<br /> AND Itis LING.'Sl)DRESS
<br /> Check ONI'130,X fo,t,..,aidd,-ss t'.,,t :-iia be u,cd for 130 I'll LFGALA`ti'D B11 LING'NOTI1:1C t l eta_S,
<br /> TANK( WNER();Z 1t;'IHO R ED SSI t:*<c.,,il.:I . " 3 ,:S..Ci1t, �`> '„i?
<br /> (is'(I3)Ola'` I LE 23 CAIAI'zL'.4' 16,CALII-CI1tlflr:t:('?L?FF OF RA-(;sL"l,A'l`ON*Sj
<br /> INS'IRU(:711(,)N FOR THE LOCAL AGENCIES
<br /> The county;an jurisdiction n;it;ai e,S are prcdoenninul and can be obtained by calling the:State;Board(916)227-1303, Th,,fa,,,:Ji1v nunnb r tat€y[c
<br /> assigned by'tht'.local<riga ni y;however,this ma nbor must be,nurnedcal and cannot contain any alphabetical ch<ar.ac tern. 11 the local agency pr k. rs
<br /> the State hood to assign^tae facility number,please leave it blank.
<br /> IT IS THE” RESPONSIBILITY OF THE' LOCAL AGENCY THATINSPECTS TS THEi FACILITY TO VERIFY"Alla t'tC:C11Y(2r°tCY OF 'I'TIE
<br /> I.NF OR\1A 1CIN, THIS APPLICATION ION C.A1'$NO E BEa PROCESSED IF THE:BOE ACCOUNT T NCI 'BER IS NO l ILLF'D IN, THE LOCM,
<br /> iA(s1z\CY IS RESPONSIBLE FOR THE COVIPL ETION OF T11F "LOCAL AGENCY USE C)ae`LY` INF'OR`vIA1IC3i`4 BOX AND FOR
<br /> TrC)ItWAItI iNG ONE FORM"A"AND ASSOCIATED IaC)RM"£3"(s)TO THE FOLLOWING ING AI7DR S4. THE E LOCAL AGENCY SHOULD
<br /> RETAINTI It;OIRR3D Ai.S AND FORWARDTHE EIL YE:LLOW COPIES TO THE FOLLOWING ADDRESS.TFIL PINK.COPY;SHOULD BEs
<br /> Rl:1AINED BY'!11HII ANK OW:VE R.
<br /> STATE OF CALIFORNIA
<br /> { t
<br /> DATA PROCESSING CENTER
<br /> P.C,BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3 a5
<br /> FOR012ORI
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