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INSTRUCTIONS FOR COMPLETING FORM "At'
<br /> GENERAL INSTRUCTIONS:
<br /> SECTIO 2'711 OFT ITLE,23,C."IIAPTER.1,6,CALIFORNIACODE OF REGULATIONS AND SECTIONS 25286,25297,ANIS 25289 OF CHAPTER
<br /> 6.7,DIVISION 201,CALIFORNIA IIEALT l AND SAFF,rY CODE REQUIRE OWNERS TO APPLY FOR AN UST"OP17RAT"TNG PRRMI '.
<br /> 1, One F't`)IsM"A"shall Ise completed for all NEW PERMIT`C:IIA"sGES or C IIA` r ES.
<br /> 2. SUBMIT ONLY ONE f,1)FORM",A"for a FaaiTity/Site,regardless of the nu€rriber of ninks located at the site.
<br /> 3. This form should be cornpleted by cither thePERMIT APPLICANT or the LCC,Al,,A`ENC Y UNDERGROUND TAMC
<br /> 4. Please type or Print clearly all rerfr wird information
<br /> 5. Use to hard point writing instrurnnet,you are snaking 3 copies.
<br /> G. Tank owner mast submit a facility plot plan to the local agency as Sart of Ore application showing the location of the USTs with respect to
<br /> buildings and landnonk s(Sect ion 2711(a)(S),CCRI.
<br /> 7. Wank owner must s lemn€locum enttation showing cor apliance with state,financial reds,nsibilsty require(smite to the local agency as Gari of the
<br /> appl'scatiort for potrialcurn USTs(Section 2711(a)(11),CCR].
<br /> TOP OFFORTi :"MARK ONLY ONE 11ENI"
<br /> Mark an(X)in the box next to the atcrn that best describes_the reason the form is being co,rnpleted,
<br /> I. FAC:IIITYISITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> L Record name and address(physical locataon)of the underground tank(s).
<br /> NOTE: Address MUST"have a valid physical location including city,state,and;tip code. '
<br /> P.O.BOX NUMBERS RS ARE I OT ACCEIYFABLE.
<br /> Include nearest cross street and name of ilia operator.
<br /> 1 Phone tramber(toast ha e aro arta code. if the night nuuT.Ivr is the sarne,(.rate"SAME"in proper locition,
<br /> 3. Check the appropriate Isox foa-`I YPE OF BUSENESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc,).
<br /> 4. Check tare appropriate bror forTl'PE OF'BUSINESS,
<br /> 5, If Facilityt'Si?e is located within an Indian reservation or other Indian trust lands„check the btta marked"YE,S".
<br /> C. Indicate theNUMBER of T"A'N S a€=.his SITT?.
<br /> Record the F?.It.A.iI s r write 1a`°n iota,space I,a sviaTe i,
<br /> TT, I'ItC3PI:R.I.A,C.)!A`N1;11 INI(l:2Alrl"1"I<)N iA.rAI)I:)ITT::.SS(A'1I.IS'I't3TaC;b)ti1Sxi.I:'I'l 1�}
<br /> coanplcte,all items in this srctionwiless all items:arc.the sante as SECTION 1,If the;same,wete':SfANIF,AS SITE" across this ;cancan. Be,stag^
<br /> ' to check PROPERTY ON,NN611"P
<br /> TPE lees,
<br /> 111, ANA OWNER.NOR A l N A AdRISY
<br /> �L4�,L 31 Lrd+ .4 T`ls e fi.['ei
<br /> C€.mplcw all teen,.,ire this scctio n,a nk,,ss ah it etas ace;ilia srarxtc as SECTION I IO „Ir the,lama,write"SAME,ME,AS SITE"acroc,s this tcz fion Be"ntr'e
<br /> to c meek`F'ANK OWN+RS
<br /> IV.BOARD()l.,lstr) -ATIl,A ION t' i 1S i 0 2A4..sE.k k:E ACC.C)UN a'NUMBER(MUST BEI C"C)'.IPL T ED1 SEE ARTICLE 5,C'IT ACME,6,75,
<br /> DIVISION 20,CALIFORNIA 19EAL 1I I AND SA<41,"f Y°CODE-)
<br /> 'arses vour 13c,:::1 of Egll lll,o ri r (1101:)t14"1'statra g fee account nu Iter v;h'aar is reqriircd x T.,re yourlx:r r.t sgpPlic:nirrn ran be
<br /> lZe >Lr a._c„a wnh"he 13c}.. e11 CT.sutc ffiz,t yon will lecei,,e a tat arterly t Tage foe retu r in s,1 oni g the SMft(61,i. )1,,, g., ,n s;a E n En._�.
<br /> number«t'g.,.;tr,s'ph ed in ko� r US'f , 11 c 1301'will c dr xsons extm.1je frt> ,p, ging the"t,>._gr twee so r t o,,'i will . tats. 'I ,: u? "a
<br /> have<.,, t: <<..a.r;.,ta.h�.: ..a.Ia t;r� lli'1 or t yctu hav a "; aa,csere. rcg.zrclaa;g t1�c.:..
<br /> to the 1101,:at the fcowi ng ad"k ,s Boar.,of Equalization,i te-A Taxes L)Msion,11,0,ilov;;-s77,` �r„tax.rnYt>,CA'94-9- a. til.
<br /> V, I'E T ROT 1,E,A 'I'S 3 t iN ANC:1.-AI_iu1 sia),N.`',iml,IT'l (:11 Kl-111:C:°OMA)LE:R ED FOR,'l,TC' u.,NI'Us 1"s ONLY,&J`,E NEC"t 10INS:Z i f 1 (.)%,'')
<br /> OFTITLE 23,Cr=.A,'11,'R'16.CA!:,,ra NIA COIN,OF EGG-TATIONS,)
<br /> hv
<br /> ,c ., :nit i
<br /> 1x>twlcunr US1,arc c,;cu-Tr from,t.
<br /> SII,LEGAI,NO'!`F,C A a '' AND BILI 4NC":1 AIN ARIR'sS
<br /> Ch,.;k ONE BO;x fc.r ter„ald ere tftat v ill g,a tt ewca t€ar 13CatTT1 I,E:C:r AI.AND
<br /> TANK OWN..,1 OR,AL:i ll€”.RI- E,',11 I;1 I'lsl°Sl-,NI'tA'I'IV';1IU1S'I"`,IGN"A q(1 D ATYFHE FORM,RM,.A`s I-NDIC A I?iD, IS I;:rr C 10'•
<br /> E. x.`11
<br /> (a)(13)OFT ITT-H23 C I1sAPTEil1 16,C'AI SI•OR,NIA CODE 0FREGULATIONS]
<br /> INSTRUCTION FORT111"1.f CSA ,A. ENC".ig..':S
<br /> The comity an f cd,.termi„ed and can he ola)trnied by cal ,t„eha feta c 1Ir» "(3;Ca)227-4301, r?,n.f„-.-Joy. lo:
<br /> ass tn..d by t4 b tea', ,.a. ,rx t v,*..ver,,lak srasnfw r,=,tet be arae rlc6ca.and cannot coWain any aaa,lrslbc;i ai c1<._sc.c:rs. at 0 1<c a. Iy, t.y T e ,V,
<br /> the;State;Ifo.,cl to L s t tc 1'aciIay;t arsal,.r,alarm v kcive it`%dank:.
<br /> IT 3S THE .?,..,`t3.`R ,al?..,1.;.A, 01° .t.`s11' LOCAL AGENCY THAT INSPECTS 111E., a ACI%:'.;'y TO VERIFY Ilil:. ACCURACY t tta,.t; S a„t. I"llf'r
<br /> LN `)RCIA`tIC.N. "I1<,S<,I irC,IC.,Ot10N "rA : C7°I'I.$1f 1p( yC£;S tS 3IF'T'tl:;Z3{?F ACC.C.Ii v"1'SE; 11f11IZ SS NC?E k iS:t.EaI1 tl`, `1"i1I.afX-','A1,
<br /> AC',?,'N(.'y ,S R.,S='ONSIE LE !OR THE C"Orar1l'1.ETTON OF THE "LOCAL t'et,>l',NC ' USE ONLY IAI°C)[ZMAlION BOX AND FOR
<br /> FORWARDING ONE'FOR-a ``A"AND ASSCIC'.IATEM FORM"B"(s)TO TETE FOLLOWLNG rADDRliSS. THELOCAL A(3ENCY SHOULD
<br /> RETAIN THE:ORIGINALS AND FORWARDTHE YELLOW COPIES TO TETE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RI-FAINED BY THE TAMC OWNER.
<br /> STATE OF C:ALIFORNTA
<br /> STATE WATER RESOURCES CONTROL BOARI3
<br /> CJO S"W.T.E.II'S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARANIOUTNT,CA 9£1723
<br /> 3193
<br /> FOR012DPI
<br />
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