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INS-I'RUCIIONS MR CI)MPIHIARM"A-
<br /> GFNFRAI,IN,1;FRU MON,';.-
<br /> L One FORM"A"shall be completed for all NEW PERMIllS,PI?RMrI'0IAN(;lJS or any FACII-XI'Y/�4J'F
<br /> INIX)RMA11ON CHANGES.
<br /> 2. FA1'BMN4'0NLY ONE (1)FORM"A"for a Facility/Site,regardless of the number of tanks localed a, 'he
<br /> 3. This form should be completed by either the PERMI'I'APPLICLANT o,- the 'I')CAL AGI?NCY UN1X-1HG'0,0
<br /> INSPFXn'OR.
<br /> 4. Please type or print clearly all requested informati6n.
<br /> I
<br /> 5. Use a hard point writing instrument,you are making 3 copies,
<br /> '.IX)P OF FORM: *MARK ONLY ONE YIEW
<br /> 1. Mark an (X) in the box next to the iten,that best 4escribcs the reason the form is 1--.rzing rompleted.
<br /> I. 1?A0IXrY/SrW,INFORMA11ON'&A1011RUSS(MU917 HE WMPIrlia))
<br /> L Record name and address(physical locationT*M the underground tank(s).
<br /> N0'FE: Address MUII'have.a-valid physical location including city,state, and Zip code.
<br /> NOT EP`rARIF
<br /> Q.1BOX NUMBER ARI.i OT ACC
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. if the night number is the write 'SA-'�'Il in proPer
<br /> 3. Check the appropriate box for TYPF OF BUSINESS OWNERSI 111'
<br /> 4. Check the appropriate box for'I'YPE OF BUSINI.`-SS.
<br /> K
<br /> 5. If Facility/Site is lcatecl-en land within an Indian resemati(m heck the box n,,ml ed 'YS',
<br /> 6. Indicate the NUMBER of'YANKS at this SITF.
<br /> 7, Record the F,.PjV 11) # Or write in "i
<br /> It. PROPERTY OWNER INFORMA71CN' F CONM211
<br /> 'L Complete all iters in thi, if rhe -rite 'SANHEAS Sffl.i'across
<br /> this section. Be sure to
<br /> III-'I'ANK.OWNW',R INIk)RMA`rI0.N&- A'1711)1,',,
<br /> AS
<br /> '�Ml�
<br /> 1. Complete all items in thi.,section, un:l ss.,�i, ne ps �N L L C,
<br /> acr(m this section, Ile sure to check 'rANK OWNYW�
<br /> IV- 1IC)ARI) OF WVALIZA170N
<br /> 1`OtCr r BOUd Of FjLuliZaIiC`u, ( 01tee a., re# i,,:or,;your pti'mIT aopivalioo can
<br /> be prcwL,444d, Registration wi,�R tile 1301, c,,itre that yooj: C-1 rj sk a&'I,,,v v-I u�yn in Tc1v)-iwhe
<br /> (f)ynills) titer gapn fee or. IhL, VuW0,ca of gafflons placca` n ir,, i"vdi (,,4t,pc,,ons 14 the
<br /> sl,forageffc so rcw'-� lot -.ot, d, dcvh,v if
<br /> 'U
<br /> rep. Or !io
<br /> V- N0(l11?f(WW'lC11N AND 3HJJNG ADDRIRi
<br /> 1, Check ONE I]K)X for the address that will be used for 13(YP( AND 11111,ING NOM!(WJ10N,&
<br /> AND DA711 'Tlffi Ff, AS 11 DICN11U).
<br /> JN! Tiff TON FOR1111,,' LOCALAC
<br /> nL cer obt:1ir"d by allinz the State 11oant (9!6)'17Cil-2,!?1, 'Ybe
<br /> l agei �wam i n
<br /> c, If
<br /> hi,�nurnf�er must bf, numerical c-anliol ,
<br /> the local agency prefers the st;7Ie • assign th, facility number!Please leave it"blink.
<br /> Pis
<br /> 'I RESPONSIBI1117Y 0F'f1l1HXX:AL AGENCY'ITIA17 INSPIX,-IN'11 ILI FACIIXI'Y'1'0 VERIIN1111",
<br /> URACTY OF11IF INPORMAIIOA14, j7A,
<br /> FS ,-PPLl(Al10N CANNCYFRE PROCII-SSED 11711111,BOE ACCOUN.1'
<br /> \1 U-1,1HER I,N 1111-ED IN, '1111i If)CAI,AGENCY IS RESPONIS11111i 110111111, COMPIXTITON OF111E'LOCAL
<br /> AGEINKUY ITSE ONLY'JNFCRMNI1N
<br /> ON BOX AD FOR VORWARD?NG ONE FORM "A'AND AISSOCINIIU)FORM
<br /> 'B'(s)1Y-1'IT1E FOLLOWIN(i ADDRE.SS,
<br /> S1'11,'I`E OF(A1,1FORNIA
<br /> w, '1!R RI�SOUR('I-r%(70NIROL BOARD
<br /> C/O
<br /> e% y1 r�SING
<br /> P.OBOX 217
<br /> I1ARAMOi-v,'%TI`,CA 90723
<br />
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