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INSTRUCTIONS FOR COMPLETING 111RA4 "A"
<br /> GE-NERAL iNSTRUCTIONS:
<br /> ST,C.. ;t.7N2';'1ltai 'I i .I:°,2?.C.I.. I'""I. 16,CALTI=ORNIA CODE OFREGULATIONS ANISSYC1`iC7NS2081201?t.?ND= OFCTlAVFEI2
<br /> Ci.;,DIVISION 20,C;1I.lFC,ItNIA IMALTH AND SAF TY CODF;REQUIRF'C3WNERS T O APPLY FOR AN IST OPERATING PERMIT.
<br /> I)One FORM"A"shall Ix cc3z>ykwd Aw 11 NEW PER'°UT C ilr"a"vGES crafty FACH-ITY/SI°'F.*FORNIA`t`I<)N CHAiRCrT:&
<br /> 2. StMN-11"I'ONLY ONE'(I)FORM, "A"for a Facility/Site,regardless of the number of tanks located at tine site.
<br /> 3. This form shmdd be ccnraplcted by od1hcr the PER1IEr,atl'PUCANT or Be LOCAL"AGENCY UNDERGROUND TANK INM%C:"€ )l .
<br /> 4. Please t.yrx or print clearly all mtlucnW infonnaEicin.
<br /> 5. Use a hard paint writing horyment,yarn we making 3 cophs.
<br /> fa. Tank owner must stabmit a facility pleat plan to the loci]agency as part of the application showing the location of the UST,,s with respect to
<br /> buildings and landmarks(Section 2711(a)(8),C°ORI,
<br /> 7. Tank owr er muse submit docur murtion chewing ccrnpli. nt svEth state financial resporfsibillty requirements to the local agency as part I>f iFte
<br /> application for petroleum USE I,Sectinn 2711(a)(1 II CCRI,
<br /> TOP OF FORM:"MARK ONLY ONE CTTiM`
<br /> Mark an(X)in the box next to the hent that best desciRres the reason the form is being completed.
<br /> T. FAC"IZ_ITY FIT.INFORMATION&:AT DRI.SS(V1C S RI C:CJMz'T ET1, )
<br /> 1, Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST"}nave a vald phys.crl Ima ion aatcWdin cil'.y,stag,and zy erode,
<br /> l'.C.t.BOX NUNMERS AIZI it�l CCl. I ABLE.
<br /> Irchsde nearest crams strc ct and mune of the operator.
<br /> 2. Ph<n c number niust h"e art area scale, 1f he nigh,,number is the sarnae,wv rte"SAME"in proper location.
<br /> 3. Caieck the appropHate box fur TYPE OF BUSI,44 SS OWNERSHIP(ex,C CTRPORAnON,INDIVIDUAL,etc.).
<br /> 4. Check the app,mprlate box for"i Y PH C:3F B STS ESS.
<br /> S. If F01,15 5 A tea a:c d wMin an Indian mscn;atiatt or ether Indian trust lands,check the box maarktd Y'I�IS"
<br /> 6. Indicato tht 'vt;MBleis of`TANKS at this,SITE.
<br /> 7. Rebs,d the l',.i",AIld#or v sac NONE' n t o space pmvi€led,
<br /> CE;.rY,'a Yc A hems in his swt,n,unless at,rima am the same as I £"Ila N L t'f1m"nine,writ, A";SITE"',E"',a rias this se ti(,a, Bs,.u-e
<br /> to Bc<r.I'RO IMT Y:0AWERTLtP TYPE taax.
<br /> Cl,.LANK OWNER Itit(;?tMA ION At rs i.)DR `S(M S l'BF COMPLFTED)
<br /> n
<br /> C..c=nalsl...e alk Ams trt'b.. s ;tf«.,u.itcss ad n _,t.m amle€ine sarnr as SIsC�.t atiN I�>,,t tse sort=c,t.n,,,; S<'LYI.. Y S 5..., as a . :rails s,<trcat. sF."'fre
<br /> IV 1'?<)AiL1'3 t F J,, ,1-,Aa__ZaY-D0N UST S l'{)kC.1,3t.FEE ACC.'t)li°i"!"NUMBER(MUSTBE C.X)MPI t; i F11 SIM,'!RTK I E..,€.,i,CI'I I R 63 ,
<br /> DIVISION Zt C,tlMa(:?IZ.NU 1III,11";Ii AMY 5.M ET Y#:t}13}':.)
<br /> l3ntcs y<>tar I3,,<a",l o,F a,rn „":a;n OKHO uor,tarne tee<ac:<;ourt nurrzlrc.r wt;zc!:is regtFlrc tI Ix f<;ra-,b at.r Cx:raY as,,,t Ei.. „ ,.z,::_.,W t 1.,�,.,crE{_
<br /> TC.,ga..aSm s ,.n to WE e,_' " r a My ym 011 w.:Ac a quar2c=d st<xM fcc:cit m in re"ning tae,IW k&mWnhwqpTm ke&x=dv.
<br /> scut-bar of Qvn5 Pock Fri you US B. The HAT wi'.1 code persons exempt Ban I,a%gi to mna ,to m"Wam,w t no kv wi. H }<,<r'""<;wt
<br /> hn an:.�exmm number e:m the;BCT or Kyo t horn arty tlRzesti m ret,arr.lts gl t);t '.�c°c or ex,�t"ptims,pa son:call dw B .,a ,16 3220669
<br /> tin Ow tIOE at t(., fix€lo ing,adlu,s I3o,<ad of k gto;a,L.wQon,101`faxes Divisiaala,1'.t?.Box 91259,Sa ,x r.bt.. ,CA i AN 21 L
<br /> V, PET iOLI1'1:.M I I'S t,FINANCIAL 1t1',Sl'C}"sts113 AT Y MUST BE U) IPL,.l l.iy FOR l'ta"i,tOLT c t;s d t 3}N.,,,:1?;i.44 g, =.7.:;;
<br /> OFUS -F 2:3,OUP•L:R 1(<,CALllCd; NI CODE Ok tIL'' .YlIONS,)
<br /> .rtCi tt l .,... ., .x.+..'�i .'t,r WC mum MXM fJ3.,,a.. alt.a ot,3:x', a.!.,
<br /> arab l d Y to St ate gon,r Rs YTH w r_:xn I_..,2J,.},UT"21"MMEL AM IN Wyl,rrtn.e01,
<br /> `i'I.I IICi, t, xC)t li I{. 1I it1\AND FILLING ADDRESS
<br /> C;hc>1,r ONE BOX Eurtt.. Alms t".m °ill 9 us d for 130111 1,FGAL AND B'qILLI'sCi NOTH'[CAI
<br /> TANK OWNER OR AC;iTRMU°ED[�FI.iUESEN r1TTVi MI ST'SIG's AN171)A"I'l:"I'lll;E ORNI AS iNDIC.A( :.l:i
<br /> (a)(E P OF TTI L.E.23 C i.'tINIX IN t A1110It0A CODE OF I2>".EGt,I,z`s'I;t(ANS.]
<br /> INSTRUCFION FOR T!HE LOCAL A(31-,N(,'IES
<br /> The cctrvy a to,,Qct.{a..t.rAx,�. <, I;,.,n t r,nu ntand can be oNar k by csa'.fs,,ng Em State.Boa r NU,n741M
<br /> ao nB by"a ,i;d, „k a, b» y ,l, a a elm " :, ; s,nt?_ s
<br /> na r� of '.nft a' tot un�r,t<.t.,number rrE,as,rst:,t.a,nttical as,cl,.aza,xit,.t'rnfaua any<ai 3°t�br t..aI o�.a.a._��., da. �,
<br /> be Sand_ and to assi n tine facMW nurrhe ,phsaw leave it black,
<br /> IT IS HE > Si �4 R ,Y ,t aFI EYL 1CLN£Y THAT1 S
<br /> ltIC, I 1 ,CY JJ YtrY a F ACCURACY
<br /> ?"IIrI.fII.«' '1 IIF 3IIL
<br /> tNIORMAT S, Tant APPLICATION CANNOT BE IT "EMED IF THE B3IACCOUNT NtYi= I IS x)i oLLr`1'x.
<br /> AGENCY 1S RESi *TBLE OR IE COMIITI )" OF TIM "LOCAL AGENCY USE L
<br /> (ALY" I°!t:)I�ilAI ION BOX AND FOR
<br /> d'£)lI.Y1 'tl�D,N(. NE I?JiiM ^1 AND t'l°s:®(X.yl.A I ED FORM"W") ICT THE FOLLOWING ADDRESS, HE:.LOCAL.AGENCY SHOi1.1)
<br /> RETAIN flE C)RIG1;;AI S ANIS TaC:)l,'.WARD THE YELLOW COPIES O THE:FOLLOWING ADDRESS-THE IIJNK COPY Sl1t3L`LD BE
<br /> RETAINED BY I HE TANK OWNER.
<br /> i`A'hT3 OF CALIFORNIA
<br /> STATE,AT E W A`FI`,R R ESOURCI:S CONTROL BOARD
<br /> 00`,`ar,,LI.R,S,
<br /> DATA PROCESSLNG CENTER
<br /> PO,BOX 527
<br /> PARAME UNT,^CA 4,0723`' a
<br /> a'93 FOF10120RI
<br />
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