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INSTRUCTIONS FOR COMPLETING F 0*1 "Aff
<br /> INSTRUCTIONS-
<br /> SEC]ION 2711 OF'I t l'L1.23,C"l1 P`l ER 116,CALIFORNIA CODE OFT EGUI.ATTONS AND SECTIONS 25286,25287,AND 2 289 OF CHAPTER
<br /> G3DIVISION Zit,CALIFORNIA HEALTH AND SAFETY CODE,REQUIRE OWNERS TO APPLY FOR AN UST OFfERAIa`NG gR.MIT.
<br /> h�n? FORM"A"shall lac completed for all NEW PERN11T CHANGES S or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ON (1)DORM"A"for a F acility/Siia,regardless of the number of tanks located at the site:
<br /> 3. This fomi should be con ipleted by either the PERMIT"APP11CANT or the LOCAL AGENCY UND1 hiCsROUND TANK INSPECTOR.
<br /> 4 Pfcaw type or print clearly all requested infonnation.
<br /> 5. Use a hard point writing instrument,yen are making 3 copies.
<br /> 6. Tank owner must submit a facility pleat pian to the local agency as part of the application showing the location of the USTs with'respect to
<br /> buildings and landmark [Section 2711 (a)(S),CCRI.
<br /> 7. Tank owner recast SUbroit 0C(Rutntation'showing compliance with state financial responsibility reglairemertts to the local agency as part of the
<br /> application for peircleum LiS"1's[Section 2711 (a)(I 1),C1CRI.
<br /> TOP OF P'ORNI;"MARK ONLY O.NE,I t'1 Vit"
<br /> Mark an(X)in the box next to ilia iiern that best describes the reason the,form is being>completed
<br /> L FAC.R IT"Y/gSITT3 INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physictal location)of the underground tank(s).
<br /> NOTE: Address NIUST have:at(atid-physicsl location including city,state,and zip code.
<br /> PO.BOX NU:4IBERS ARE,NOT ACCEPTABLE:'
<br /> Include nearest crass street and mine of the operator.
<br /> 2. Phone number must have an area code. If the night nurnlst r is the same,write"SAME"in,proper location,
<br /> 3. Check the appropriate box for TYPE OF 13USINE'SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF 33L SINTiSS.
<br /> 5. If Facifity;Sae is located within an Indian resersratiou or other Indian trust lands,check the Eaux sharked"YE"S".
<br /> fs. Indicate;the NUMBER of TANKS at this SIT`[:.
<br /> 7. Recrrd the,F:.P.A.I1).#or write"NONE"in the spaev.provided.
<br /> M PROPERTY OWNER IN1 ORNIATION`&Al),3RESS(„c.11JSTEE COMPLETFI))
<br /> Complete all hares in this section,unless all items are the same as S1 C'l7t` N i,If the Baine,write;"SAME A5 SITE"across This sczctiot.^lie scare
<br /> to cheeck PROPERTY Y OWNERSIII? I'Yi',:box.
<br /> III,TANK OWNEff INFORMATION&ADDiU SS(Mc 1ST Iii COMPLETED)
<br /> Curnpl. c all itenis in link section,unics's all iterna are,the saane as SI CTTON I;If"the:s,4me write,"SA ll:AS SITE"acioss dik secticaia, Be sure;
<br /> to check TANK OWNEIkST"I'PL box.
<br /> IV.T3C)i+RD OF EQ ALIZAT'ION[ S F STOR'GE,I l I3 AC..0 1JL,'°"I" L M131 ft(;`IUST"BE COMPLET t.I).Sl,'f3 ARI}C lJ` s,(.;IIAI'`ll"p,6:75>
<br /> DIVISION 2 ,C 11PI1 C12 ,!IlIs.ael,`I'11 A I)S, t It"t`Y t t)h3Ts.}
<br /> tact,r�-E>ctr I3,r<arz?s>f Iii,ta.al�r;a!iutt{1sC11I:)G�s€ stp:agc Ice actut:rtfrturnlsur�,1:icPt is rccgt,iYcd Ex=forF}°otir jsaa°asrt�l I>Iie:.tt�t,t�«s''.:,I}r�>ccs�e<i.
<br /> Rcgisnwion with tf;a lt01_.will cnvun. that you vvil,fcceive Ia quaiae ly st€iral,c fee return in reporting the*ii)AM6(6wil )p.:r;;;illon fcc cite on the
<br /> atttrnl?cr 0.ga,lsir;i ptat,.i�r,.vt>ur.s l's. I,t„,3L1;`;tisrs3 cc:ie gxtsoats exean}atl'xon)paying tlro st<,rtit,c fee sLki:.Sat.n.,vr.,t...,,be.�ta, If o,c a,d=.;not.
<br /> haa a at) aca.ou.tt€a:zir,litsr V i. h tri, BOE or if'you have any questions regarding;the fee or cxsrtil2tz®ri..,ple asac.til,l,,a B ). ai T;f 3_'2 ti>tY-)r„tuft
<br /> to tits 130 11";at the fol o"N..ag adiidi,�s llo;,rd,a.Iacltz::ti t,icm,Fuel Taxes Division,I".i)_Box 9 d K 9,S<aci.z<rwoSri,CA 9!2', . -,;MQ.
<br /> V. PEITIRC),.I.t,11 1 61'l•INANC.'irlL RLIll'ON I111LI`l'Y{.MUST BE C"()MPLEIT'l:I3 IaORj1II"i ts0Ll,l:N1l UIS1`s,ON 'I,SFE SIX"!IONS "r,
<br /> O 'II"tI_�:.Z_,C.11.l. dI,,'R 16,C,"A11.11 L).?i IA C ODI-,O R GIU11,A]If)t°s'S` )
<br /> a"a«x k f used Ly fllc,is"<ctc.r a;'e>r p ,xst,in a,a,vihtg the i ed rat ford 1Stt L.a_,i,ftai ros'.onswility dly
<br /> S atd aqw,nc;as%,eN as vara*,gCn6ca„r,US]1 slam exei;I„from this r;;cillher.ent,
<br /> VI_LEGAL NOI irI£°,1TION AND,'LUNG,ADDR'E'SS
<br /> Clic xt,°e t,,.;. ibJt€1 eiai vvilltx, .n1., '10]'I!LEGAL AND FILLING NOTIFICA1TO`S,
<br /> I`.s,NK(ybE'Na..}s OR e'tl.,1lIORIZI.l.i REIT',I�SENTA HVMUSTSIGN AND DATl;'l"iti;FORVI AS 11.DFC 1 i 1). ,.>i.i; .,i ?1f),S"_;:€t
<br /> (a)(13)OF T T ti 23 CI, 'P hli.,- 16,CALL€OI NIA CODE OF Rl GULA'lTONS.f _
<br /> INSI UCTTOe:FOR ltil,LOCAL"s GENCIL
<br /> The coo itt ar J aris,diction nutnfx r are and can be obiained by caping;the;State Board(916)2_27-43"(3. t 1w t..ci ity rna nbcr at,ay^I
<br /> assigned by the local'zag,.ttcyt however,this number must benu esic al and cannot contain any alphabe icaal-chaeac r�s. If the ks ea l ag;cncy prof ret
<br /> the Stats, tea assign the facility number,please leave it blank,
<br /> IT IS °1'lll" Rlt'SPONS[BILIT'Y OF`IIIL If)C AL AGENCY THAT INSPECTS.THE FACILITY '10 VERIFY THE ACCURACY OF111F,
<br /> 11F
<br /> INFORMATION. THIS A1'P ICATIC3N C~'ANNOT BE PROC ESSED IFa THE BOE ACCOUNT tiC;4t131:'stt IS:`'<C,T FILLE D IN. THE,LOCAL
<br /> /°GEINC:Y IS R1SPONSI13I,I3 FOR THE COMPLETION OF TTI. "LOCAL AGENCY USE ONLY" INFOR IATlON 13OX AND FOR
<br /> FOR.'r'AltDIN(3 ONI;FORM"A"ANIS ASSOCIATED FORM":3 (s)TO THE FOLLOWLNC's:AI DRI.iSS. THE LOCAL AGENCY Y SF OUI,t)
<br /> Ri,;t A!1`1'1111;O1 K31-NAi-S AND FORW ARl9 T HE YELLOW COPIES TC)THE FOLLOWING ADDRESS.THE PINK COPY SHOULDBE
<br /> Ri i'AINI t)BY,l HE TANK E)WNL,R;
<br /> STATE OF CALIFORNIA
<br /> -,STAiL WA'fER RESOURCES CONTROL BOARD
<br /> C/C) , r.1:.E.P. .
<br /> Intl"l"t`VROCEfSSl3NGCE,-3 ;
<br /> RO.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> F126R1
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