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<br /> I ST UC;`"T I _ I FOR COMPLETING F `` "At,
<br /> G[,NERAL INSTRUCT IONS:
<br /> SHC:I'IG a 231 OF"I r I.E 21£.;WFER 16,CALIFORNIA?IA CODE,OF REGULA`"IONS AND at..0`I"L('x ;S 2 2 f>,:s2A, AND 25289 0 CI-AP Twit
<br /> 6.7,DIVISION 20,CALIiaOF NIA IIEAL311 AND SAFETY CODE E®i;C)i.;RE OATERS TO APPLY FOR A'4 USI C3I ERNITNG PERMIT.
<br /> I. One T'GIt aI"A"shall he connplmal for all NEW I'IEtIuUT C HANGES or any FACILITY/SI"T"E LNPC RNIATION CI IANG.ES-
<br /> 1 SUBMIT ONLY ONE,(I)FORM"A"for a Faachity/Site,regardless of the number of tanks located at the site.
<br /> Ii. This form shotald be cornplewd by either she PF,Riv1IT APPLICANT or Be LOCAL AGENCY UNDERGROUND TANK.Ia'S'SPhC"'tOR.
<br /> 4. Please type or print clearly all requested,irtformadon.
<br /> 5. Use za hard poitnt writing instrument,you are making 3 collies.
<br /> fi. 'I"auk owner must.sttbma�f,� '40 S Dart of the appltcat%s t�awiaa9 the location of the L STS wkNmp ct ts� ;)O(t
<br /> buildings rand lan(fn2atrks sec tzars 1 a�} �C .
<br /> 7. 'rank owner must,submit clocurnetntation Omwlg comhliancxe ME state financial respomibility requirements to the local ase
<br /> application Eorpet.roleum USTs(Section 271li�l.�};i
<br /> 'lY1I'(3I°2f(AW1 �UI I '�%�Y(ONE I I Ii,e1"
<br /> ylark an `t ase > n t to this item bat best the reason the forts is being completed.
<br /> I. FACII.I"ry/SI`E,INFORMATION&ADDRESS(MUST BE CONN I,,E'I1,D)
<br /> 1. Record name and ad&vs(physical location)of the;underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and zip code. V
<br /> ,�.'C Nrl7l�t ER;ARE NOT AC.0 EPI ABL Ii,
<br /> T� Y�,l#i�ta5i 4 X Qs st'icct and antenna of Be tTcratcre
<br /> 2. Phone number must line an arc>a`rcxle, If Ac n0litrnumber is the same,writs"SA,NI's"in proper It>c:atiou.
<br /> 3" Check the appropriate box.for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,ION,INDIVIDUAL,etc.).
<br /> 4. Check the apprrTriate tax for TYPE OF Bf SINESS.
<br /> S. If'IracilitylSite iS lcrcatc.ci within an Irzcli<un rz.s,n,at1«rz or Driest Inciiara tars;E<anc s s §kt9 e iarkcd"YE
<br /> , 'I ,sjvq ,,qj jq A Pei
<br /> 6. Indicate.the ti[ihlllliit of TANKS at this SI IT,
<br /> 7, tZtn and be IaY A.ID#or write"\C)\E"in flee sp.wc provided.
<br /> II', PROPERTY f�.)Vd\SItINt�f.7Et�A"ClU4&AIM)RESS(LILIS"i"Iii:CCMPLE',CT'D)
<br /> Campine in items in this Worn,1n I rss an nttsrns are do same as SEC31ON Y If the samq write"SAME AS SI'I"I"across this Won. lie sure;
<br /> to check l'ILfJI'SItTY f}yVRIitSl EII'"E'Yl'li ben ,
<br /> III.TAMC OWINI't I\I£)IZMA ION lig Aa}Ix.WSS(MIST BE c.'(JA.I'a.E' ED)
<br /> £`.ting slate all hems in H s seethr, tE'a.: all hems are do same as SEC`["IC)N L If the same, attic "SA's E AS SITE"<actz.s this�c n, l a ,ure: s
<br /> to<ttUek Alli GAAAIT l '1'c.,, ,,y. "a fly.CTA r.`0
<br /> IV AGAR; C# �S VAIAXj 0\t T S rm�"18 :t a 'S+l„C l?tL s IIIA CC)YIl'l.l."a:iiia,Sl_,L.Aa..,C ,_i: s,(A i Al'
<br /> DIVISION�U,C,AI.E aC?lC�i.A a�._, T,l t t AND D SA. A C(M)EY
<br /> l:,a}crvoa,rT3c,ud2l p l..hm twhoi. a .cna1 fc an:w,rr,t,twe}.a, WWA is myAcd?x.f-,.Ec,I<<.tE .,'t „li -,,... "a',Q(mw.—J,
<br /> ICigN <a1.1;m 0 1%a?CM i.M s ,.c eat)na ail._c00 a quourtsi"tmyc fee rvamtn in inporibg ,t. SWA,� � � � aa,,
<br /> T 310 all >� tea sex r r:1 , , 1,I t 1,; (t 1 t r
<br /> lnaeeF, a,. t.1.. ,n, „lt.r, i,a1Cih� ! $C? ti (YCis�t� t CtT $�,I �3 ESI
<br /> t I ti,i -st. Jue 1.,,ns r..2, ding da.s ke m ux <i.,1zn"Pon
<br /> M10 IIG: at 00 t l t
<br /> .� q Www Wad aQmKwho i0nd IcLx.t,S F005n,P11 it,9r "^ l-'s ail ..l CA 9WbvQ1
<br /> V. l'I�.1"ZG I n ti; ENE l:A;1`ra L W„I ) S% r ,n, I U S r.
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<br /> p}I.T M 1 Cl X131 l1 t1 CAL nRNQaQ WMG ULAYION S
<br /> any 1 c t;_s a;,Wz a.0 My,as .<-H.- ,,.,. t', a"c't..e, ."nom 1hk._.l<<i. ..W na<
<br /> VI ILO: 1_ aC3t�.l'1t It} ,.x �)itil yes 1 A a 0 € 0 0
<br /> 0_v.3,_a.ONE �E, L.... ._.� �,...;5 ... . __. .,.i lr, Po,,€l , „ ._Ai-..'+>
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<br /> TANK 0, SEI,II.OF,tip l tl
<br /> _ W.1R..S`._._s_'a"t ,IVO i:'IbST EG;AND D.c,E TIM FORM.,. ..:RW�_.
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<br /> ((911 OF ITI z_1.23 CII,AI'T silC IS,CALaf-s !VC CODE DE O RLG'i. r iO°°SS.J
<br /> LNS'I`[tl C"T'IO FOR .III;I,OC A .AGF',SC,.,;S X
<br /> Il —MY an in aakqh n...,en ,G.e pi a ky mmind<.W cera he Es}nzahied by W,¢g die Sum,A vn6(9 4 22 ,hn in,y
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<br /> asst�te�Et by t-= r,_a,i <. . �. .0 ,-, _<r„<a im numc,.>rA an,l cnianat n,tuu,any Ai,a_aYAQ Wax .z a,. ,_ w r ,
<br /> c;� t
<br /> me SW C Hand W a n n”,d,_4€tu,=., . ,yea owe h Wank,
<br /> ITIS IIiI�i CA THE WCAL AGENCY lard INN C zS PH-, e l Yr a .( tf ",OF I=I',:
<br /> INFO MA TON. 'i 111 . s'.l`.,?l ia.3;i .re rt kC . E.u.< aei LCrL._azCC Cse,Ri.l Al Alb1.l�_t f .�t.t?,I,Li - '11HE'LOCCAL,
<br /> AGENCY 1S REM sly,` BLE DOR Hll' CO. \lP11T'Tbt..rlA t,t Ill:; 'LLOCAL AGn,NC,Y USE, ONLY” Y.rC),C`lAIRON BOX AND FOR
<br /> FORA tatD> G t)'sE I ORM"Ay AND AS,�sss.:3 1 D .URM-Wj O THE a i?:.1_C)rA'AG.AI>rNESS, rrl LOC'Al,A(,1,,RC S T('ILiLl)
<br /> IZl:TAI I HE ORIGI�.Al S AND i t.)R`,r;ARD"I'H."I"Y11"I'Low CGlril:S'I`G I`€iii FOLI_ V I G ADDRESS.THE FINK CRY SHOULD BE,,
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<br />- � FOROW1
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