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<br /> GENERAL INSTRUCTIONS:
<br /> SiiCTIOiN 2711 of:TITLE 23,CIIA11TER 16,CALIFO a4A CODE OF REGULATIONS AND St?CT'IONS 25286,2528'3,AND 25289 OEr CRAlYFE
<br /> 6.7,DIVISION 20,CALIFORNIA TIEAU111 AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UIS"C OPLRAT"LNCx krERA1IT,
<br /> 1. One FORM"A"shall be completed for all Nf>'4ti Z'isT2_TWT CHANCES-car any ACC3>:i'FY/SITE IFIFC RIMA°TION CHANGES.
<br /> 2, SUBMIT ONLY"Y ONE(I)FORM"A"for a Facility/Sire,regardless of the number of tanks located at the site.
<br /> m.
<br /> 3, This forahrsuld be completed by either the PERMIT APPI-ICANT or the.LOCAL AGENCY S., DERGROUNI)TANK INSPECTOR,
<br /> 4. Please type or print clearly all rer{t�esr is f<> atic�n.
<br /> S, Use a hard point writing instrument,year are making 3 copies.
<br /> 6.
<br /> Tank owner er must submit a facility plot lan to the local agency as part of the aIs;rlicati ra shcsaing the location of the USTs wrath respect to
<br /> buildings
<br /> nd NI�,,-Imarks
<br /> 7. 'Tank.owner nsu ,�btnitld curnenta ion showing compliance with state financial res onsib ity requirements to the local regency as part of the
<br /> application for Ixaroleti tt C ST"s;[Setta<na 2711(a)(11),C:CRJ,
<br /> TOP OF FORV1."NIARiC ONLY ONE,ITEM"
<br /> Mark an(X)it)the box etc tto the;tcrn tha!best describes the reason the forni is being completed.
<br /> 1, FACRITY/SITE UNFORlv1ATI€N&A37T?TtESS(MUST BE COMPT..i:7` D)
<br /> i, Record nanse and address(physical location)of the underground tan (s).
<br /> NOTE: Address MUST have a valid physical l,x;ation including city,state',and sip code;
<br /> P.0,BOX IN Iv1BERS Alas:NOT ACC;FPTAI LE,
<br /> Inoladc nearest cross street and came of the operator.
<br /> 1 Phone number must have an area code:' If-thenightnurrsber is the same,write"'SAMfi"in pr proper Ideation"
<br /> 3, Check the appropri4tc ox forT` P,I OF BUSINla.SS ONN ERSHIP(ex.CORPORATION,INDIVIDuAL,etc),
<br /> 4. Check the,appropriate Iron f2 rTYI'li OF,BUSINESS,
<br /> 5, If F acility/Sity is locared within an Indian reservation or other Indian tru tlands,check the box marked"YES",
<br /> 6. Tenn;ale rh Xt.MBIi;R of TANKS at this SITE
<br /> 7. Record the E,P.A,If)It or write"NONL`to the space prcrvailed.
<br /> Il. PEZCSPLSf'l2'�''i3';tEaa4;'CI'f:Int,'4'�S�tI�� AI?Il��r:�5{�itl�7T3hC°CI�IItI,3i"Tf:L?} ,�
<br /> Ccnlol t_.all merits in this st"010 s,unless all iEetns are the-,;rine as SECTION l;If the ss te, a,.e"SA's,a AS SI l I 'acros,this,,r.6on, Be state
<br /> to chuck PROPE'RTY;OWN 1.I6llii'TY11E box,
<br /> Ill,'l ASK t7��' Ii1Z l:`<I°C}3�'�,1.k"l":OSI�.Al)1)Rii,`iS(S1IT"I3E;COV9PI.I;'I`S<.13j
<br /> Cz,rr.ls u,,all iwrns in lhis section,urdess all itc€xns;are the same as SECTION 1;'If the sart-w,w6t,."SAME AS Saf'I"I"ax rsss t}n ,,e tion_"Rc,sure
<br /> to chock TA1n;,:ttV`ERS I"s`Iq-box.
<br /> IG,BOARD OF E.QU A_,"I.,s„'(Ii 1N;.:`.-l1 i"IOR GE FEE ACCIOUNT UNIR R(Iti MUS I'll r;CON”I'Ll.I'1.i7.SFY Ati a I(."LE 7,C i lrlla l.,R 635,
<br /> DIMS;!(}20,CALIFORNIA HEALTH AN'D S,�FET COIX[')
<br /> 3
<br /> , t
<br /> Eraie.r v uar If,mrd of 1.e,,.ah as m(801:)L a i storaagc fc°c account h-Jo ,,, „% tvmrii apnlic:,lion r-".t b,ptoc,a�r_x#,`
<br /> R{'L,.ti4 7tti>;t} r Ii I 1".1%<}S.��'1i1 C1iSC3 t }'�'ii�)FF S-:t.r s..Eb'ti.:!quarterly S 3 i4yu fee,r�/iSgi,S.Y1 rf�)}E i't g t�'t "�{:.i.l r , �3(t,.,.l J 7 t :s k<.JY,
<br /> Te lit E} ,, III code p;rsons exr r:3st.'frort jtayim, h,,�c,r,a �:".c.so n i r,ta tis01 mA 1 ,°,"t if;<>-I d not
<br /> h ave.:at acee>«.ainulnbc_with:11w,13x7yr i sou have any qu sstnMr rr g,arefMe Me,l_w s,r pleas,,, c:<_h,Ery,But. <t at lu r..7 9`40 or w6w
<br /> r.,thelif.}it ar t1,u f<>`,1c>a,a a tele �,sl,:<ar::ofEsr,.a;3i.ratiun,Fuel"Pexis Division,,'.O.Box 9,12 .?t,i. r
<br /> V, ri_ .. ,< ('
<br /> ldvnts
<br /> .I th. rr tn,xt";a a cd by 11w ono a ndika open�lkn,an a a�,ting the,.Federal and lit im,,a<=,a_t.., .r_:.r ,r�r:�._ .r�r..:.E ST',. v
<br /> any t vita,ral or slaIc agt a,,y as well axi non petrolcum I.S"i s?iie xe ngtt from.h i
<br /> VI_LI.CrA=, [3 I al-I{ '110,'r AND a BILE ING AID: RIR S
<br /> C "Ck€ N E BOX for t.¢, +ddress that w ll bu used for BOTH Ll,'GAL AND BILLING,NO t'II"1C°A',ION ,,
<br /> TANK OWNE' OR AUT11t)islC.11D R RE"PRESE"NTATIVE MI ST SIGN.l;vi7 DAJ 1: Il ,,1F0R\1 AS IN'DI",1 a 11), 1 S'E :l;l f,,,t . 3 ','I i
<br /> (a)(13)OF TT T i.}_23,CHAPTER 16,CA11FOIT`IA CODE O3 R GULA"1`EC)a S.,
<br /> L'S'II C C E IC; ;^41i{ 113?.x;t)L AE.AGENCIES
<br /> The c at.r, eiy f urrs,a.ci"on numb rs a€e predoc ain l and cau Ise obtatnc d by calling the Sate flo rd(9.6)L'u, 4303. z Iw.#w 31 IV rrct.t,ntr r ray E '
<br /> assignc:c)15}the 1<>LaI aar,c°.ttc1:;.Itcstswar,this nuxtsber rt.ust;�e nurnersaal nztcl carzncrt co€a€ain aarxy allair abztis.'al z.aiawt�rs. If t].cIal arc ric:y I k�:fzss
<br /> the State hoard to assign the;faciuiky number,p,.caseleave it blank,
<br /> IT"IS 'ilz I1#.SI'O�S1111i.1I Y OF I'llFs LOCALAGENCY THAT INS a'I;C.I x 'allE" I AC:1L1 s y C{') t`1 RIFY"I IIL ACCURACY OF THE
<br /> LNFOI220ATTO,N, THIS APPLICATION CAN" OT BE PROCESSED IF THE BOEACCOUNT NU;NI13E1C IS NOT3'aIL1.E.I9 IN, THE IX)CAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE. ONLY" INFORMATION BOX AND FOR
<br /> I'ORWARDING C?lall FOR�`,I"A"AND ASSOCIATED FOR `I3"(s)TO TIIk':FOI:I:O IINC'x ADDRESS. THE LOC:AL"ltcrENC Y SIIC3ULD
<br /> RE FAIN TUE(RK3LNALS AND I=fIIZVa`ARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS,THE,PINK COPY SHOULD BE',
<br /> RE<"i.sL'NL D 11`r'`TI11I TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S,W,E.E.P,
<br /> DATA PROC:F SUNG CENTER
<br /> P.0) BOX 527
<br /> PARAS OUN C.CA.90723
<br /> 3' s " FOR012ORI
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