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MOWN— -,
<br /> INSTRUCTIONS FOR COMPLETING F*M "All
<br /> G.F"NERAL I:°`SIRUC,` `IC)N ;
<br /> SECTION ICJ 2711 OFT 111,"1 23,Cl IAP`ER.16,CALIFORNIA CODE OF REGULATIONS A'.^D SECTIONS 25286,25.'.87,AND 25289 X F CHAPTER
<br /> C,,7, ?VISION 2(I,CALIFORNIA HEALTH lT AND SAFETY CODE REQUIRE t3Wa`E S O APPLY FOR AN USTOPERATING P1dTi ITl
<br /> I. One F'{711111"A"shalt be completed for all NE's PEI- IT'CHANCES or any FACILn-Y/SFTE.TNFC)RMATICINT CHANGES,
<br /> n. SUBMIT ONLY ONE(I)i,,o m»A`frac a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This farm should be completed by cither die PLRINti"I'APPLICANT yr the LOCAL.AGENCY UNDERGROUND TANK:INSPECTOR
<br /> 4. Please type or print clearly all requested information,
<br /> 5. Use a hand point wriUing insmunent,yarn are making 3 copies.
<br /> 6. 'T"axnk ownta must submit,a facility Plot Marr to the local agency as part of the application showing the location of the US`I's with'respect to
<br /> buildings and landmarks(Section 2711 (3)(8),CCRI,
<br /> 7. Tank,owner must submit documentation showing compliance with state financial responsibility requirements to the kt ail agency as part ol'the
<br /> app'lieation for petroleum USTs(Section 2711(a)(I 1),CCR)
<br /> TOP OF FC)RM�"MARK ONLY ONE VF tit'
<br /> Mark an(k)in the:box next to the item that best describes the reason the forni is being.completed.
<br /> 1. FACILITY/SITE INFORMATION&AlyDIU31 SS(NNIUST BE C'0;411'l EIT.t7)
<br /> i. Record name and address(physical location)of the underground umk(s).
<br /> NOTE:Address NIUS`l"have a ralidflhysical location including city,state,and zip code.
<br /> l"O,13OX NI,fNiPE11S ARE NOT ACC'EI'TABLE:
<br /> Include nearest crass street and name of the operator.
<br /> 2. PhonenurnberrnustMve an area coda. 1f the niglit.number is the sarne,write"SAM f,,"iti proper location
<br /> 3. Check the appropriate box for TYPE OF'13USI1NJ11SS OWNERSllll?(ex.CORPORA11ON,INDIVIDUAL,etc.).
<br /> 4, Check the appropriate box for TYPE OF 13C SI-NITSS.
<br /> 5, If Facility/Site is located within an Iridian reservation or other Indian trust lairds,check the box marked"I`I-S".
<br /> 6, Indicate theNUMBER BER of`FINKS at this SITE-
<br /> 7. Record the E.P.A.ID#or write NZ ONE"in the spice.provided.
<br /> I1. PIIOI'ERTY'OWNER INFORMATION,Sa ADDRESS t4tU'S"a"", lII:CC)IviPLE1"Iil7)
<br /> Complete all itc:rnc in this section,unlessall'items are a:hs s=ani,as SECIION 1;If the sa nae,write."SAyti;AS SITl:"aa ross this section. Bc scare
<br /> to check PROPERTY OIN>iERS11iP TYF i3 Iarx.
<br /> U.I r itNK OWNER P.a\a E'?13.1TAON S.AlwlI�S ty'l,"S z 1311,Com III-FTED
<br /> ;`t.
<br /> Cc>n.t.l..a a12 ilcms in t}.i. scc,at;r,r,,ttt,tss ,,a„rt;s areihe same as F;C,1i 7N t,at dic,sane,write"SAME AS SM, .,bt, 3,t,.: s tt4t , Rv stare
<br /> to bl tc ck, ANK CIA,Na_l`.:1`y i 1 tic>x,
<br /> �I�.13C)A?i?Cir iv(Jt,is :<'1(f?N t; t_31ZAC.i.t 1_r . C�CwC3P:N I`y? dl.l3(yS [ IiL Ca)tIt 1>li'I ED,S1:I=.A 1 ICLE 5,
<br /> 4tc>rage fc o stoic .,rt.;3r rturl t.t<, ;1.7 t,'e.r,_i ,a.,�. .1, i,,,
<br /> .1:501;Vail Coal'pn,rsoss ex znpt"i""n-,t,lymg t!,�.?,,ra,,i a i_1,i,r. 1, <t„ P ye u do not
<br /> 11:1 c.an,,Cco unt t..ait b r t,avn tit::BOF or if you havo any questions rest,a dim,,dhe iso;of c;x. a.p,tisst ,a71r.,.,�c at1 9i`,1,22, >',_»
<br /> V, I'Z:`i`lIOLI, I-`I'l USt llNANCIALRE S110NSIBI I°l4'('r.l`S"i BE FOR 0`I .s",I1,1 , c fic, Is
<br /> 1"Ti-r LE'1,Cfl k, :1,!�1s C;;IL.IHORNIA_ODF 0, R1`(,'1A,ATIC.NS,)
<br /> Id" .t., u,>,d by i[. ,n i,t LLL,4 die,x c,.c:,al and S_;,,
<br /> any 1 Cd s'd ors,-l a.3 n. y as we is as n�. R ,<ct<� E3.?`�!'s ars,exemp!iron;this r ?c+tnnatartt.
<br /> Vl.LEGAL tin)11PI('11' ION AND BILLING ADDRESS
<br /> Check O'\E BOX I€te ihc=acres that 1611 bvu a cd icu BO Uf LEGAL;'AND 1:$Ll.7,T1*G .;1`1t:Cls"l[�3}il_
<br /> TANK OWNER OR A[;`l'IiORIZEID R13PRI'SEN A'I IVE MUSTSIGN AND DA11T11F FORM ASD,Dl(-',Ali D.
<br /> (a}(13}C)'S��"t�I'LI:?:i r:11�11'hli� lti,f"Al.?3°C?Is:Ntrl C,E7L73 C)I^'R.l>C1(;I.A'IICNS.}
<br /> IN'S'1R UCTION FOR II UE LOCAL AL A(,I,"NC II"sS
<br /> The county,ar,n j sa..a3.ction Ivmnikx., arc l,o,dCi,(',1TnncJ and can be obtairmd by calling the St<ato;Board(16( 227 13€3, !hlwia. ,..;;ct Cr..,a>
<br /> assigncd lkly t'tc ,c;:a?t g,m: .y;ho"o er,this nuini-ic_nssrst,be n,tmcdcal and cannot contain any a?p;r.bcucraa clnir.i- rs. I3 lie;lc cl-d!igcnr, hri born
<br /> the.°state llio,rd ,ass:r n;he faci°ar.y number,la°ua,a.leave,it blank,
<br /> IIx l s I'M", RFS!ION i>W Ca 'I)r,THE' LOCAL 1A',}.NC,t ItIAT INSPECTS 11111,, I A `=,t'; Its y t r..:Y '11H A(` . .0t_I OF'111E
<br /> Is 1 ORc ,I,VJ ION, TII,S APPLIC..11,(:)N C":A sNt;)"i"f 1 Irla()C.E.SSI I7IF T1IE:BOF AC~C OUN I'N U'VI FIR IS N:01 .11:1.1°,1,1 IN, 'I III,,LOCAL
<br /> AGENCY IS, RkSI'O,\ illLF, FOR Tlil,', CO3,\,1i'1.FTION OF ' lb—, "LOCAL A `E'IN :Y USE ONLY" 1NVOh'STAIIO' BOX AND FOR
<br /> F'ORWARDIN(3 ONE I�ORNI":y"AND ASSOCIATED FORM 13"(s)TO T`l1F FOLLOW LN ADDRESS. `I'lIE l,.(')CA ,A(;I-NCY SIIOI,'[,I)
<br /> RETAIN Hill ChRiGI AI,S AND:FOR:)h ARCS 7 FIE YELLOW COPIES TO THE FOLLOWTSIC3 ADDRESS. THE PINK COPY SHOULD 13E
<br /> RETAINED BY'11111"C'?1N'K CJW3aER.
<br /> `I13C)T C:ALIFC)FLN
<br /> TvTA
<br /> S"I,A.`S'E WATER RLSOURC S CO'7TROL BOARD
<br /> ,CIC)S,il EZV,S,
<br /> DATA PROCESSLNG CEN"I":,
<br /> P,O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3-�5
<br /> FORD12DRI
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