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<br /> INSTRUCIAWK FOR COMPLETING .' ttz 11
<br /> G'. EIS AL INSTRUCTIONS:
<br /> IONS:
<br /> SEC.l1C) 2 11 C)I°"I,::_I;23,0 lArrER 1 C,C:;'AI.11'41RNIA C OD[El OP gl tlULATIONS AND sE °t`(.C)NS 2_,2*;i,25 87,AND x528 a OF CHAPTER
<br /> AIr'1`E
<br /> &tDWIMON2ti,C'A:,11'£RAIAU A1.iit.�NDSAFETYt.4.DE1'EQUIRECit ERS To APPLY I!`EAli i.s17C?MU eTING1']..tNH,'.
<br /> I. CW I ORNI"A"shall be oenjKta a Por a 1 NEW 3itUMn' II A':CII:S or taray FACII,I'rYiSll'INFORN4A i K)N(IIANCIA,
<br /> 2. StMY1IT ONIX ONE'(!)1,01Uvi-A-bor r "Facility/site,.r gar'la ss of th e number of tanks located a the,she
<br /> 3. 15,foan shotdd be ccuni,Ie ed by ria,t._r the P1,1 v IT AZ PLIC:r1=NT orthe LOCAL AGENCY UNDE LxltC?i:;CD TANK INSPECTOR,
<br /> A Please,tylac or print clearly A Mquestm id rna<twnw
<br /> 5. Use a hard ponit swri[ing instruancin,you arc making 3 coples.
<br /> Ci. Tank owner must submit a facWu p. t pI to the.Iroc al a x cy as part of the eppllcac'soat show ag the location of lae US°ls v°. cct��
<br /> buildings and landAnar 3f ] )1 ll
<br /> 7. Tank owner must submit c ocurxe nt t6m,showing cmipiiance with state financial rrsponsability mquircrnants n)be Mescal a mem as pan of IV,
<br /> applicationRwpLirolctamI STs[Scctiot2'1Y46J efts, rbis W'
<br /> TOP 01"FORM:"'MARK ONLY C)NIE 111i,M"
<br /> Ylrtck r xt ohlooja
<br /> to the ion that bs t s the reason the Nolen is bhl rnanplet�ed. �
<br /> I. FAC R ITY/SITE INFORMATION&ADDRESS(MUST BE CONIPL E I`IED)
<br /> 1. Record name and address(physical location)of the,unduglround WAY),
<br /> ;4'C)TF,: Address MUST kava;a valid physical l se,at,ion rr 0"ing{6W,:atate,and by cc,de,
<br /> �yy11,0,BOX NUMBERS ARE,,1N'OT ACCF',T� LYMBE,
<br /> i,a .OrCst Whnnvt amp.nElme of Me olac utter,
<br /> 2. Phone munbcr must have mum aide. Lk We right number is the same,write,"SAME"aat proper location.
<br /> 3. Check the.approptiate Am.in TYPE OF B SMAS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> C Check the appropriate box for TYPE OF BUSINESS.
<br /> 5, If Facthty%Sire is located within art Indian m.serntion or ether Indian tma lap W1janarka;d"YE '�ansJ doisM \191qq3 flem
<br /> ea
<br /> 6, Indicate.the;tit.ilstl3EiR of TANKS at this SI Yt?,
<br /> 7, Record the ETA.A.ID#or write"NONE"in the space pm ided, 93NISONKM 8V
<br /> ft .1 doisM 1 iqiqq3 E19nC
<br /> I:1'. PRO I'ENTY OWNER INFOI MATRON&A DDI [;SS(NI,USTB C`C),MPI_I I1D)
<br /> Complete all items in this secdom wrley all Arns are the saan^is as SECTION Q If&e same,write"SA,UIE:AS SITE"across this section, Besure
<br /> to cheek PROPE.RTY OWNIsRS lJP TY('Fia`t:)ox.
<br /> III.TANK OWNI?.R INFORMATION ah&AI)DRII .SS(MUST BE CC)AIPLIETEED) lsoo& sdb A3 to ynsqmoi)hO tioinl..I
<br /> Complete NJ Ams in this cc etion unless all items are the same as,S}C,l"(1ON 1,V the same,writes"SAME AS SITE"across this se,.�t'cpra. B ab
<br /> �e
<br /> tocilicclsLANKO?VNE161'YPI,box, x � ' 9 _ .
<br /> I"1NIVI �g I� QC>N * 1 i t:AUX)E)I, NUNI BER(Ai US-F Ii I.c0.mPL ri,,D,SFH AR I"CC`l E 5,C II.AP1Iil ern
<br /> I')IVI. ?. 2t, .1 .I t?t�AI.1 II i,1 .,lI Ali:)S,tt I�;"1"A C.C)1}I:,.)
<br /> Brae,yoarr Bo ;d of Eq t it.iira r,ICLO USTmmqy We acooasat number h ch is r.q,uied beine ymar p nu t aWhyhm am be pg 3 c"cj,
<br /> Ry;srrr Am&I Me BOE MH ma w dw you v,aii p uc&a a a;c.a"dy,st.a qc%re.mna itt re,Nn€a g tttc `a{)U t,qWK0 pa.';a'la,. Rw d ..,&-
<br /> runt:r aft b,,t i I L, tE vtsirr . .s. 'lt ?(},.cti a a code Ch tscrp s exr I' t nor a,>z as,11 c ,t rt
<br /> hasic ma,. on ni A r a ria 3y o q E 1 it�,reg; i n„ rata ISE.a.r i i ua 3 €}�
<br /> w 1h z BOE,am toltos as b a...',;._,Howi ,E,ys ait..tt n 101 Man Dh asa p€,?'.t:)_HM 9 t_Sr7 t,;S.a,.wvc�ai,t , y W,, 501,
<br /> 1Z a c)SSI Y QR:TF RJ )Ai,t.,il,D R)R I'll AC-,,-Is
<br /> C)h`1?U i 23 Ol `I9 [C i < S to�.JRN AC ra ;(21 rE{ '; s llON )
<br /> p,, u
<br /> un d b 7.. 4: �. >}9C a i.I,in F iat,,the 1 cd,,,,'.raI and Son 6..<.li:, d nspomhao v _ .....,. t,.`�„4 AM OM08
<br /> any NOUN ur Ssaac.,af a noy as""ll as nat an trct,t cath 1Y&a+a;netr pl lra n to revIrc:rne.nt.
<br /> YIIICx1I_ E)I'11C Ll(tl AN,') ADDP ss g` .q
<br /> C:hmk ONE BOX tart}.a,a,it'r_:;: 0.1 .al't a Rn l3flIA UGAL,ANDHHU)4;iy£;3,,I�;C:'a',.(I r
<br /> TANK OWNER li OR At llbA VI.)RRI r SENT AI IVE MUST SKA A?C1)DATE Is THE I°£)iiM AS 1NDRI-A!111
<br /> OXIY fala'1U a Ii 23 f:11AP"E ER 16,C:,AI_,01 S`A COD!,',
<br /> I:"�;ES"1'12LtC`TIC)N FC7R"Alli 1.{'}C AL.A{"rl `sCIi;S
<br /> The ceuray anjudAkAm ac crates am Inudamnined and can be Onaine d by c hats r the Sow Amete(95)2 1 0111 f `;v a + t na ra
<br /> assign d ;y�tna al:q tii3
<br /> ocy, °eev r, tris nkAnhe,r rr u b paum deal and camwt coma! airy a'f''tsl>Laky ch,aa mn. f....�
<br /> the S"tc BowBowd w awli aokk ti raaart b ,please laawe it beak.
<br /> ITIS h111i RE',SPONTRILTIT OF THE E i t CAL AGENCY THAT iNS11.C;"IS THE FNC°It.ITY TO VERH Y 'FIIE,a1C'C::Ui1 AC"Y OF11111"
<br /> INFORMATION. TIS AITIACATI:ON C aAN'(n'BE,PROCE'SSE'D IF IIIE;BOE r1C:C:(.>Lti"l"\l.Ata;I:It IS NOTEILLEM lN. THE LOCAL
<br /> AGENCY IS RI SiSC)\SiliLE FOR "IIIE C:£1)\11a[,1 TION OF TIM "LOCAL AGENCY USE ONLY- E"iFORMA'IION BOX AND FOR
<br /> FOIti rARIANG ONE I C RY-A" AND ASSOCiA[a.I)FORM°'II"{s)TO°[`IE}''CdI.Z.0?WI;tiC „AI)a REM. TEE LOCAL AGENCY SI10111,I)
<br /> MI i 1I\ I HE€t zIOINAl-s.AND POR` `ARI) I IL Yla,I.ow COPIIas IC?'4IiI;FOLLC W[Ni b ADDRESS,THEPINK COPY SHOUILD Bhi
<br /> Ri,'I'MNED 13A 111H TANK OWNI.R.
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