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<br /> INS . L- COMPLETING_ � ? "Aar
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF T'IT'LE,23;CHAPTER TER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25296,252,87,AND 15M OF CHAPTER
<br /> 6:7,DIVISIONT20,CAE.IE•"C)EZMA HEA1,111 AND SAFE'TY CODE REQUIRE OWNERS TO APPLY FOR AN UST€ PEER A E ENG PEiRxtTT,
<br /> 1. One FORM„A"shall,be completed for all NEW PEIL IT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2„SUBMIT'ONLY C3NF (1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site,
<br /> 3, This forte should be completed by cither:the-PERMIT Adglxl ICATor the LOCAL AGEItiCY 1INDF'iR C3EtC3tiND TANK INSPECTOR.
<br /> OR.
<br /> 4. Please type or print clearly all requested information,
<br /> S. Use a hard point writing instruinernt,you are making 3 copies.
<br /> 6.Tank owner must submit a facility plot plan to the local,agency as part of the application showing tine location of the USTs with respect to
<br /> buildings and lan�marks[Section 2711 S)(8),,CCRh N
<br /> 7. Tank owner mi,,a stnl mh.documentation showing cbmplian6e with state financial responsibility requirements to die,local ftgeha y aas's:att 0 tine,
<br /> application for fx;tmler m USTs iSectio n 2711(a)(t l),CCRI,
<br /> TOP CTI FORNI,`NMARK ONLY NE I 1 L;,,1°
<br /> I1ark an(X)in the box next to the item haat best,&etaribesthe reason the form is being coniplated.
<br /> L FACT11T'YISITE IltiFOR;as1ATION&ADDRESS(MUST BE COMPLETED)
<br /> L Record narrne and address(physical I(xntion)of the underground tank(s).
<br /> '
<br /> NOTE. Address IMUS'T`have a valid physical location including city,suite,and zip erode.
<br /> P,O,13OX NUMBERS ARE NOT ACC EPTAF3LF.
<br /> Include nearest cross s:rect and name of the operator.
<br /> 2. Phone numb r muse have an area cWe, If the night nuinlxr is the sarcne,write"S.AIME"in l r:per locatir`ri.
<br /> 3. Check dhe appropriate box for TYPE OF BUSINESS C)Aa`NERSIUP(ex.CORPORATION,I-NalkA IDU AL,cr.c).
<br /> 4. Check the,appropri etc N)x for TYI'E OF 11E,SSTNESS:
<br /> 5, If Facility/site is located within art IrnchAn rc se,rvat.io a or other Indian trust lwxis,check the box€na<t ,.d YES'°
<br /> 6. Indicate<ate the NUMBER tai T'tA KS at this SITE � F
<br /> 7, Tincord rhe E.P.>A.Il)#or Write`NC NL`in,he spare provided.
<br /> 7E. I'IZC1I'h:L"I'Y C)Y;'�I°`.iC L"�i'Cl, ;�I�1"fICTti&AC7lTiC1;°SS(�1t;ST`E3I:C:(9�1E�l.ti'[Isi;7}.
<br /> `C,orx*i,I„tc:all,atoms in utas sccta tn,nzntcss all atenns are the same as oli."[`EC.)i°d1;lk zhc ,at.,v,s im Aa,S11 Eas v,,,tip,7..t r s,n. rlr sum",
<br /> neve}rock.PIZ01113,RTY CaSr's'N'�ERSHII1 YI'l:b<nx. '
<br /> 11:11.TA K OWNER I.`:I°CTI MATTON&ADDRESS(MUSTE3L CC)IAIPLE`H,`T)
<br /> Ccnoraplew all itt bas in this section,unless all items at,-,the same as SFC'I`0"N 1.I, she-'a.ric.,v ansa "SAME AS S,,7 , u,t. ,!6,,,s,_.icr. >, .o=e.
<br /> tea>cYhc,A TANK O "SF RS T`YTSE box.
<br /> IV,IMARD 01;t01''tALIZA�iIONIUiSt SC 1)t'�aA�GEi(.;.1.;
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