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INSTRUCTIONS FOR 1
<br /> OF-NP-,RAL INSTT2UCTIONS;
<br /> SECTION 2711 OF TITLE',23,CIIAPTE'R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,252$1,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFOR-NIA HEALTH AND;SAF'FTY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PLRMFL
<br /> 1, One FORM"A"shall be completed for all 0.I:fid PE m11T C l A NGES or any FACILITY/SITE INFORMATION CIT ANG~S.
<br /> 2. SUBMIT ONLY ONE(1)FORM"rA"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This Loan should be completed by either the PERMIT APP11CANT or the`LOCAL AGENCY UNDERGROUND T"ANR INSI'13f:°°I OR?
<br /> 4. Please type or pant clearly All requests tt inforadon.
<br /> 5, Use a hard point wf tisrig instrument,you afire making 3 corpies.
<br /> 5. Tank owner must submit a facility plot plan to the local agency as part of the applicationshowing the location of the UST"s with respect to
<br /> buildings and Iandhiark [Sectir)n 2.711(a)(S), .CRI.
<br /> 7.'Tank owner must submit documentation showing ccsmpli aricte with state financial responsibility requirements to The local agency a,(cart,of the
<br /> application forpetroleuan USTs[Section-7711(a)(11),Cts'I<)
<br /> TOP OF FORM' ",T ARK ONLY ONE ITEINT'
<br /> Mark an(X)in the box next to the itern that best describes the easen the fore is being completed.
<br /> I. FACILITY/SITE INF`OR_NIA'FION&ADDRESS(vTL ST`13T3 CC3;2P F TEI�)
<br /> 1, Record name and address(physical lc>eation)of the underground tank(s).
<br /> NOTE:TE: Addre ss MUST have a valid physicaa location including city,state,and zip cede.
<br /> RO,BOX NL'Ia113E,'RS ARE NOT ACCEF`FABLE`.
<br /> Include nearest crass street and name of the operator.
<br /> 2, Phone number must have an area code. Il the night number is the same,write "SAME"in proper location.
<br /> 3. Check the appropriate box,forTYPE C:Tr BUSiNLSS O INERSIIIP(ex.CORPORATION,INDIVIf3l AL,etc.):
<br /> 4, Check the appropriate box for TYPE OF BUSINESS, '
<br /> 5.If Facility/Sne is located within an Indian cesectiaEs`o a or other Indian trust:'lands,check the box marked"YES",
<br /> 6: indicate the NUMBERcfTANI;S:atthisSITE.
<br /> 7. Record the ET,A,ID#or write"NONE"in the spam*provided.
<br /> II. PROPfiRTY ONVINER lNFOR-MATION&ADDRESS 13EOMPt.ETF' I))
<br /> Complete all items in this section,unless all itcrins are the same as SEC ZION 1,If the same,write"SaA,IixF. AS SITE"across dais section. 'Be sure
<br /> to cheek PItOPER'I'Y OWNERSHIP'IYPE'box,
<br /> BT,TANK OWNI:R INFORMATION&:A DRLSS('i,,R:ST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTTON 1;If the same,write. SAS>`z AS SITE.`across cilk seedcase. Re sure
<br /> IVBOARD OF EQUA1:IZAT IO LST STORAGE FEE ACCOU T NUM111-- (MUST 13E C".<)N'll'LE I E;t),SF`17 AWFIC.'LE 5 CIIAIrF`FR 635,
<br /> DIVISION 20,CATJitOR eI.=A IiLAL 1I AND SAFETY CODE.)
<br /> E_r. :lat3r Il,aCa of .tiu.<.za i.>n(l3Cla.1 STs tasaga fee account.number ohi h is required before yoar lx�.gat aJpplat..F"?y.+E bi,plocc�swj,
<br /> Rcgisulltio2 pith tile,BOE will tnsa:are that you will receive a quantrIv stolsige fee tetunr in rel w1ilig Ine,' 0JX)6((,walk)ly r r,.,1,rt.., daiw,ori the
<br /> rumlicrof i,a.l ni;pl iccd in your I,STs. Ibe FtSli will code persons excrnptfrcrrt paying the stor,er,c,ice sir li t4Mm,W. it ..;t 83.. if .€3a is rex
<br /> hd e,an acs oust nurnber r li h the BOE or if,you have any questions regarding the fcso of .xc�,aa, t_serr,,ail �a�n,i.a 1 die[R),",atS',1,3221,,t,O)s>r wrrae,
<br /> ,to the 1.R)F at the following aadtess Board of liclualization,Incl Taxes Division,11.0,Box 942879,Sari an'.(rn.* CA 9
<br /> V. fETRt)1.1:UM UST it3N.`f;\CI AL RESPONSIBILITY(NIUST 13a'", OlulPLETE'D FOR PE,I ZOLIFIL:M t.;`Ts ONLY,S7 FISECI IONS,I"'a' ,;(E<)
<br /> OFTI TLE 231 Cil, IujllR 16,C:rALIa ORNI,A CODE.OF RI:CIUl.z`TIONS.)
<br /> Tei,t.tfy the naetl.exl,s)used by dw owner and/it operator,in n:cetirrg the Federal and Saatc financial aw,,le,a..:;-.sUS
<br /> any Federal tar Sire rag enCy aa'ss ell as non-pcstrol„um US7 s are exempt xrorn th k r;gctireniernt.
<br /> Vl�L1,GAL NO]I KATION ANIS BILLENG ADDRESS
<br /> Check ONEBOX f'or the address that will be used for BOTH LEGAL AND 13T1_LL Cf\C7"l'IIEit,.A 3IC)NS,
<br /> TANK OWNER 1R AUTHORIZED RETRESENTATIVE IMUST SIGN SAND DATE t HE f t:R.M AS 1JNDJC.,A'4TUi, t`a,l,"4iTA`t.NS >r)
<br /> (a)(I3)C?I°'1TTLE 23 CIIAl"I'l,"R 16,CA LF=C)R-N'1A CODE 0FREGULA"T ONS.
<br /> INSIRU(TrION FOR`T`I E LOCAL.AGIlNC:IF,S
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State,Board(910)227-4303. The f'i c iliiy rt,imber may Esc
<br /> assigned by the local agency;hoeevcr,this number must be numerical and cannot contain any ala,laatstzc:al ebarsctltrs. If the Io ai agc'nt y lmfcrs
<br /> the State Board to assign the facility number,please leave it blank.r
<br /> IT IS"I`I 1I RE'SPONSIBILIT'Y 01, THE LOCAL AGENCY THATINSPECTS THE FACII.I`I'Y TO VERIFY 1,11E ACCURACY OF THE
<br /> LNFORNIATION'. THIS APPLICATION CANNOT BE:PROCESSED IF THE BOE ACCOUN I`NC,'ML3E IS N tTI'FILLF;D IN. THE I OCAL
<br /> AGENCY IS RI,'SIl0'NSIBLE FOR THE, C"OMPLET"ION" OF THE "LOCAL AGENCY uSFs CJ,y- 3N1°6ts11ATION BOX AND FOR
<br /> FCIRWAICJINGONI', OR4'1 A"AND ASSOCIATED FORM"}3"(s)TO THEFOLLOWINGADDRESS. THE LOCAL AGENCY SHOULD
<br /> RL l ANT"1`141:0kIGlN A1..5 AND FORWARD THE YELLOW COPIES TO THE,FOLLOWINI r ADDRESS,'ITIS PINK COPY SI16UL HE
<br /> REIrALNLDBY HE'.TANKOWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> DATA PROCESSING CEINITER
<br /> P.Cl.BOX.527
<br /> PARAMOUNT,CA 90723
<br /> 3`93 FOR012DRI
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