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INSTR*'IONS FOR COMPLETING WINI "AtT
<br /> GCItAL,INSTRUCTIONS:
<br /> SLCTIOIN 2711 OF ITLE 23,CHAPTER 1 Cr,C:AL.IPORINTIA CC7I OF REGULATIONS AND SECTIONS 2 296,25287,AND 25289 OF CITAferER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNTERS TO APPLY FOR AN USI'Cal';::1 ATING d'IMRm]T
<br /> L One FORS "A"shall be completed for all NEW I ERI IT CFIANGES or any FAC;II.i'FY/STFE INFORMAnON CHANGES,
<br /> .2. SUBMIT ONLY ONE(1)FOR "A"for a Facility/Site,regardless of the number of tanks located at the site,
<br /> 3. This fords should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY C,'NDt`RtslC(1LrND TANK JNSPP "I`OR.
<br /> 4. Please tyri or print clearly all requested inforanation.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner roust submit a facility plot.plan to the local agency as past of the application showing t.dte location,.ifs the USTs with rersrpect tc
<br /> buildings and lar,Irrtarks[Section 271 1,(a)(8),CCR],
<br /> 7, Tank owncsrrzar t submit documcntattof
<br /> n shcsw9 6rrpliatroe'with st:€tt fimureial responsibility aoluir.5r� ,o the 10,81agency as pad of the
<br /> application for p€froleum t;STs[Section 2711 (a)(1 1),COIF.
<br /> TOP OF FORS:"MARK ONLY ONE ITE
<br /> Tu';1°
<br /> Mark an(X)its the box newt to the ifem th.ri'tyst d6seribes fire reason the form is being completed,
<br /> L FACI.I TYfSITZ INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record narne and address(physical location)of the underground tanks).
<br /> NOTE: Address MUST have a'valid physical,otcaotion including,city,state,and zip code.'
<br /> P,O I3OX NUMBERS ARE N6T ACCEPTABLE'.
<br /> lnulktle neansi cross strec t a #,.raazras,of tdre operator,
<br /> °
<br /> 2, hrrtae number natter have an area csxle. .I.f the night number is the same,write"S NNE"in pioper locatienr.
<br /> 3. Check the appropriate box for TYP Ot BUSINESS 0WNERSIIIP(ex_CORPORATION,T.NDIVII'UAL,ctc).
<br /> 4. Check the appropriate box for TYPE OF BUSTNESS.
<br /> 5, If Fiacilrty/SiLe is located within an Indian reservation or other Indian trust lands,check the box marked YES",
<br /> �,.Eeadc<at<.;h`c"`I�L?1�2T3F»dt of'I'r�;tiKS of fk;i�.`S,I'I:Ii, -, -
<br /> 7. Record the E',P.A, ID#or write:"NONt," in the space prwiided.
<br /> LI. I}IZCk'EI2TY OV+1;'�I It L'�F�OIv't4A"[`JC)14 6'r AI)I)R1�S 3(;v'IUS 13I"s C;C3�SF�L�TFL))
<br /> Complete all items ire this section,unless all nc",rids are the carne as aS"EC`1011,'I;if gate sarn ,write`;`Al 1,"AS SSI!T.`ac t>,, c°t{ter. 13e sum
<br /> to check PRC:)VE,RTY OWN I RSFI>t'TYPIC txsx.
<br /> HILTANK K OWN t I:tiFOIOVIA PION&A.DDRFSS(MUSTBE COMPLF?Tfil))
<br /> Comp e tc all items in this section;winless all items are lire sarne as SEC FIOti I;1f the Samw,w r.re°`ti,c,%11.AS `k,"acloss d"is tri=,xd_ 13,.°strr€:
<br /> to checkTANK Ob NERS'I'PE box,
<br /> IV,BOARD OF F:QLAI I'f_ATION US `z'I ORA GE FE E AC C iJl,4T NU BlF3 R(MUST'f31-'COh,:I„L;T°�i�. of L I�I ,C.:f Ailf t;I�
<br /> DIVIS10%; 2),CAI,1T 011NlA I IE,AL T'II ANO SAI I."f Y C O1 i, �
<br /> Enter you 13oarei est I`qu rlrr,;etit:air(IdC>li)TBS l steerage fee account number r aelt is rcgt,inc d twfk)re e r^1 :start r,p)ilat „r,cari be Ia ocessexi_
<br /> R,e),istration with the B0131 will ensure,that you will receive a guart(nly stoaat,e f e,rcttarn in re Ixr;in tae$0,0 F5 Clomill_)1 :r t;allon 1'ee,deet,on the;
<br /> rturitb r c>i f.slle >I ac d i t y<uzr 1 s'F'<.
<br /> TI)c I3Ol's will code p rsons exe rpt from paying t} sWrai C f.c. r of �c tt. if von do tart
<br /> have an account nnainbvr with dict t3Ot;or if you have any questions regarding th",dee or �lsr''3 or�ws.a
<br /> to tho I;Oi.'at the ft>lh>w.rt�a1tt, ws Boafd of:;yuala sntiorr,Fuel I'ascs 1)iviait)n;]'E .`3
<br /> b 3 t i) she%3, za,:n:,its,{ � } �''
<br /> V� 111 11 OL t M'USTFIN ANCIALRES ;10°Y.Sill 11' (' UST 131 C(YC 11'I.I.II'.DI'ORIl I1i' 1.°.t °i-1
<br /> OFTITLE23,CHAPTER 16,CAa_,1T()C�1A CODE OI I'�a GIUL.Ai ION s.) i)
<br /> 3 lcatt fb 11111-MW(s)toed by the c w ;r arc{/or c)perato :n nu,,eLing the Fckl ral a rd state
<br /> any F,dcr,a<ct S1 sic agency as ts'crI a,new`-lx taolcunl t,Ss:s are excer;ptfrow,this rf.qwkvg,.c n.
<br /> V1,LEGAL 1aC)'i111OATIO;tiAND ILLINC';ADDRESS
<br /> Cheek ONE BOX fol the address that will be imcd for Bum LI GAL,AND BILTANt r NO`'1FW"A i"l,ar„s'
<br /> TANK OWNE'RORALllit?h-1ZEDRl.1,PR `sENTA IVSMtSTSIGNANDFAIE111I t`ORI -'l AS[-C,tCA ,,;). ;,
<br /> (a)(1:3)OF—I 11,li 23 CHAPTER 16,CALIFORNIA CODE O' RLGUl,A'`I0 ,Sj
<br /> T'0:4'IRUC1ION l"OR THE LOCAL AGENCIES
<br /> The c oucly an jurisdiction ol'i n as are pwdeiennitied and can be obtained lay:ailing dic Stall,C3.and,, �7 13'0,0 "I Ea „���1its ,),..,
<br /> assigned by Sher I e.a'1 age rey;hcnc ever,this number must be numerical a€xd ca not contain any alph;abcuc,,d dhaTacts rsi if ifi.v I.1.41 .f e,cl,l,ae', ,s
<br /> the State Board to aassigra the faeiiity number,please leave it blank,
<br /> ITIS THE REST O-NSIBILITY OF Tlil: LOCAL AGENCY THAT INSPECTS THE FACILITY '10 yriv,�IFY Till, ,tet"C'U;€ ACY Oi aI1
<br /> 1.NF�OF2lIATION. THIS Al'T'1_ICAT IOii CANNOT BE PROCESSED IF'T HE BOE ACC OlJ`°ti`P N MBf.71 I t.)"'I`tl,I.l l)IN, I`TIF LOCAL
<br /> AGIieC'.l is 1�a.Si'O SII3LE FOR THE COMPLEI'IO1 OFQ TTIE "LOCAL AGENCY USI'l ONLY" EN�' RNIATION BOX ASt) FOR
<br /> FORWARDING ONE l'()R.M"A"AND ftSSOCI:'i"I`ED FORM"B"(s)TO THE FOLLOWING AI DR- s& THE,LOCAL AGENCY asl OULI3
<br /> RE:TM- 111”ORK31NALS AND FORWARD THE:YELLOW COPIES rO TFIE hOL.LOLSL°v'G AL7DRESS.`1411]PINK COPY SllolllI)JIE
<br /> RETAINP")13k a'TTE TANK OWNER.
<br /> STATE OF CALIFORNIA -
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CYO S.W.T:.E,P.S:
<br /> DATA PROCESSING,CF TER
<br /> -PI O.,BOX 527;
<br /> =" PARAMOUNT,CA 90723
<br /> FOR01201
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