|
POOR T*ONS FET NES FOM ,'ATT
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE,23,CHAPTER 16,CALITaC RNTIA CODE OF REGULATIONS AND SFC`DONS 25'246,25297,AND 2.5259 OF CIIA.M-E 2
<br /> 63,IN ISION 2t1,CA 1.IFOR-NIA HEAL"I'II AND:SAFt:°.`T`Y COOL REQUIRE;OWNERS TO APPLY FOR AN 1.1SI'OPE'Rr'TI:;Ci P,RAY5,1'1',
<br /> I. One t°C>ilaM"A"shall Ise completed for all NEW PERIMI l'CHANGES or any F40LITY/SITE LN FORMATION CHANGES.
<br /> 2. SUBMIT ONLY ONE(l)F=ORM„A"for a Facility/Sire,regardless of the number of tanks located at the site.
<br /> I This form shodd be cii: pleted by Emu Te I'lrRNTI i'APPLICANT or the,LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or prhn clearly all requested information,
<br /> 5, Use a hard point writing;instsvn,uan,you are making 3 copies.
<br /> �6. Tank owner Faust satba it a facility plat plat,to tire local agency as pari of the application showing the location of the US"1 s with m'rpect to
<br /> buBdtngs mad hn Inalst , (`SeWon 2111 OYN CCR1,
<br /> 7. Tank owner in,. ubmit documentation showing compliance with-,tato financial responsibility requirements let tire local agency as part of the:^
<br /> application for Petroleum USIN¢S=6on 271 (ayl1),CC RI,
<br /> TOP OF FORM:"IMARK ONLY ONE;Ida NI"
<br /> Mark wr W in the box nest to the Kann Haat Best cicsrribes the-maron the form is being completed.
<br /> L FAC'UITYISIT,INFORMATION&ADDRESS(�I ST BE C Of,,T'LETBD)
<br /> 1. Recant naaw and arlrbess(Physical location)of the a adergroond tank(s).
<br /> NOTE Address MEIST have a valid physical hsca ion including city,state,and zip code.
<br /> P,o,B6x NLii'vlB RS ARI: ACOOP A(-'CIIPTA'Ill,l3.
<br /> Include ncaamst cross street and imars of the operatcar,
<br /> 2. Phone number must have mi arca ucxle. If the aught numbe,,r is the same,write"SANIE�"in proper low on—
<br /> 3. Check Me aWropt mebox fc>r TYPE OF BUSINIrSS OWNERSHIP(ex.CORPf)IdA'IION,INDIVIDUAL,etc.),
<br /> 4 Check the aapptvpa.ir e hoax fear"[°YPi,OF Iis SUNI'S&
<br /> S, If Facility/Site is located c itlain an Indian reservation or other Indian innn lands,chuck the box marked YES",
<br /> 6, Indicare the NU,,`sII'1oZ of"[A;NIC,r o this£SITE.
<br /> 7, Acmd the EPA.A.11)A or write",NON E;"in tire space.provided.
<br /> I.. PRC)I't:RTY OWNER I dFORMf'TION&AI)F)Rll°SS(NIUST III:COMPLETE',D)
<br /> Co,='gvwc all hems in sit sc.wdon Unless all Mms are tile,saunc as SECTION 1;If the sanni,wr4e"SAN;IE a ^SI i IT testi dis s ctacr . He u.m-,,
<br /> co check laRO aLRTY C I:TZa i<'I Yt luax.
<br /> III TAN'"r";OWNER R I\FC)lZ"bird" ION Lf:Al DRIV',S.`S(IUS'I III.,CCelt}I E,"IT',D)
<br /> C'osri}aletc all ite,a,,s in Haas sniaon,isnlcss all€tams sire tJte-,tine as`sI,C.I2C,b''d t;It 2,hc aamm,wr.�s ;S"_ .E ASSIT""',s" a<a,,s 01is z.:',aFsa. T ure
<br /> to ch,ck'fANK Oa.' NI S TYPIA Israx,
<br /> ly'„BOARD OF EQUALIZATION 10 t Sl t7EZAOE FEE ACCOUNT NUMBER(MUST BE C;ON EII,t,`.,).SEE ARTICLE aCLE s,+.x:;ts'M 4 635
<br /> DI ISION 2f1,CALL!ORNI,I III A LTH AND SAFETY C017I".)
<br /> t.a=.uryour Heard<.1::a,.LxaEh:f,OEM t ;:lmap fee am,ur,titaarn?3u0a;.aa,Y<..;irc.I!.,;E,ac., ., ,.a.Y t<,;,W s,ki.—t5 . „�•=cez.
<br /> Rq "A 00 low y A M W W that .,,i WM W.&C a,{mnerly o rer;to sum in my. y on W so e=A ,PT 040 NZ w ..
<br /> '' i!2'it dot`.'Cade S.i;1P14 n"C,}t as zl.9,- t:'i. {....fv :�;,„. •. L,<S. ' ,�. �
<br /> ls<a�✓e an„_..o,�.[,au.;ta>c., ,, ,;�4ic),c<s 3 yt:s a %;a9
<br /> lute BOH M Ox woo' a���i..... z, d vt Epal.�,"t,c,a,I ucl Taws L'a*.,.hm,PAY i9caa ,. .'9,S„�a �:t _.t CIA,
<br /> V d'..tKE).l_?. "el.�`a, IIa*1`a. t 1.�.[.iCL`,={)'y;Jll=...`I`". tiS>�,S"il;..<..Cl`tiE'LH,la>J?C FOR a'1F11.f)I l.UM 50,_ONLYnTH HAS 2A
<br /> any
<br /> wwA or Im agm,y as weUa_.x,o plmi-in iSds a..,ex-r ptB n,orkw.a,..zaa,..A,
<br /> VI IAT,', s1..j )I, ':., FR M)13111, Cs ADDRESS
<br /> cl k Oita°BOX;'n eve.,.a„ E<., Wdibe on(!for BO l1 I_LOAL.AND BRAIN(,(,NO,H !CATIONS
<br /> TANK 0'A'Nt„Z ORAL-11€ MI `3TSIGN AND I).ttti THE t,e-:' AS 1",:sICA'i
<br /> 011.saf0 TOIX 23 C lIAVI' R 16,C AIJFOR' IA CODE(Y R,s`i IMATIC_INS,j
<br /> I SIRUC ION 1,01\11111f,',LOCAL AGENCIES _
<br /> lie<e>s,,,,y <i..,..;as,act,c,.nu=nCa m am E.re.r'e.vWa,z,,,,M nd can be obtained by ci,;t,i,c;the,o.a a.Board!916)22'7
<br /> assii_n d by,the I._"l ag,ncu,lxasever,this nw;alser inust be numerical and c umot.casain any saps? rdai clt"z ano s, if Be Imaj aWn,y pvqm,
<br /> Me St w Bond W ass"n sc{!+ei.iiy nesmbe,please have it,blare.
<br /> IT IS THF F R SI'C NStlaUXIV OF THE IDCAL AGENCY THAT I^sSIOC aS THE FACILITY 'ti`.? 4a.LZI S iI13d AC(1U1ACy`
<br /> lNt°C)iCl*,I,1TION, 'I fill'S APPLICA1 10,N CANNOT 4 B PROCESSED IF THE I3CyI:.ACCOUNT N"1 .,1.,;i1;._R IS NOT i s{.t.I,D IN (:l:<,,a, `L `
<br /> AGENCY IS RES.' ;N SltHA,, FOR Tltt; C'C?."L'1PLETION OF TIM "LOCAL AGENCY USE ONLY" i a _:.'i.ta Ci< a BOX : ,s.a, ,(.?ia
<br /> INC}IZWS`kt)lN(+ CJ; F}.#'RM"A"ANE)AS OC:IAI`I I7 FORld"B”{s)TC)'I Et;Ia01,1:;() INN r I)DRESS. THE LOCAL AGENCY SI ,1l LD
<br /> R?."I AiN`DSII;C.}i?aC N.= LS AND s=C)RWARD THE YELLOW COPIES I'D THE FOLLOWING AI7I NESS. ME NNK COPYSHOULD
<br /> RELAINED BY'l HI-,',TANK OWNER.
<br /> y l`A"I`E OF CALIFORNIA
<br /> STATE:W ATER RESOURCES CONTROL.BOARD
<br /> C/0 S,Ve+.E.i RS.
<br /> DATA PROCFSSENG CENTER
<br /> I1.0,BOX 527
<br /> PARAMOUNT,CA 90723 pg-ppqi990R
<br />
|