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i U# FOR i °
<br /> GENERAL INSTRUcrIONS:
<br /> SECTION 2711 OFTITLE LE 23,CITAI'"I'I::Id 16,CALIFORNIA A C ODE OF REGULATIONS AND SECTIONS 200011081 AND 25019 OF CIIAT n-',IZ
<br /> 63,DIVISION 20,CALIFORNIA HEAL,111 AND SAFETY CODE IZEQLIITtE OWNERS TO AMPLY FOR AN USC OPERATING Cr P13R.,-,311
<br /> 1. One FORM"?t"shall be completed for all NEW PERMIT CHANCES C3ES or any F°ACI1.,I'I` /SITE INFORIMATION CHANGES,
<br /> 2 SLIBNIF l C)x l Y ON (1)d C.RNI A"for a s sci?izy/Site regardless of the number of maks located at the site
<br /> 3. This form shra dd lac,completed.b;, either she 1)C RIMI T APPLICANT or the LOCAL AGENCY UII�T)I`IZCIIC3L3�1�TANK I l QST I:CI'C) ,
<br /> 4. Please tyro or Penn e;l;rat-Iy all recti siod information.
<br /> 5. Use a hard point ara mg aai r v usm iota we mAinkf Y cwies.
<br /> 6. Tank owner rau n submit a,facility pkat plan to the local agency ars part of the application showing the loalstisincd the CtRTs with respect is
<br /> buBdtnl,s anal'Animals[Secthn 271 S 0)0),CCRI.
<br /> 7, "Tank owner„"in�, �slflr it do ut ctxtatia s showing ind c omplianc with;hate financial responsibility requixcrnants tat-be lacal agency as part of the
<br /> application fere pc fs;Aleum US't`s;[Set hon 2711(QU 11 CC)1LI,
<br /> TOP OF FC)RNL"MARK ONLY ONE,I I T;'.`,l"
<br /> &&an(0 in Us Rox next to we 3S?;an on but describes Me mum Be firm k bang selm md.
<br /> L FACiR ITYI ITE 1NI°OSCMA'IZO;v&ADDRESS(MUST'BE C OT P E' ED)
<br /> 1.. Record name and address(physical I(Kation)of the underground tank(s).
<br /> PsT E, Address MUS`("have a valid,iy' physkal location includingcity,ciy,state,and xa rode-
<br /> P,C).13O NUMBERS ARI,,NO AC.C.I:Y"i AI LE,
<br /> Include_eatr u Crcos stmt mid name of tate meratim,
<br /> 2, Phone naan2ht r must rove an area code, If the mitt number is the same,write"SAME"In pmper location,
<br /> „s. Ciacck this a ,,,c, &v:l ox for T5 PE OF1:31.SIN has`OWNERSHIP(ex.CORPORATION,INDIVIDUAL,
<br /> 13A P
<br /> 5 If Fac tz s}S:c is ass,1,e exat€tan an Indian ac,craattott or other Indian trust lands,check the bm r sarktd nTr, -
<br /> . .Itakiicato,Isc.NUNIBEA of TANKS,at,his SITE.
<br /> 7. I unni Te.L;.I°`.A.ID Ia€sr Mite"NO Y in to sliace prvvitTLd.
<br /> 17. I'RO[IL<IC"I'Y O)A,'f,', L',Ik Olt ..MA'110.N&AI)I)R,i,SS(M S`T'61Is L`ONIPI,ETED)
<br /> C caaslAme all trans;.n ads section utaless all deters arra the saute;as SECTION %If me smrm;write"S.?M AS Sl 1'E"across this section, Be sure
<br /> uicheck'P(fE:SI'RTY C}tk'SkitSltTI'1'kE?Nx.
<br /> IIT.°I AINK OW NEIL I:tilr()Ss.AIATION c~s Al DRI2 SS(MUST BE CtaNTLE'llisl))
<br /> „. ,
<br /> C:'a>;n,�.�ac all.atetra to i.ats woke a,atlt 4s eras atetsas;are;ilio scacsa.,as hEC,IiC}` l;It be stss'str,u,s.,Aw."SAMEAS SITF"Facict.s tz,:,s ,c.cti<rz. Be starcx i
<br /> in)cA k T A K 0\\NI_as S TYPE;Fsa x.
<br /> IT BOARD OF tat;U Alj.Z A't tr N,::,r S I ORAGE FEE ACCOUNT NL;:41Tfs S fmUS I, C.",(lMPLEH'PT),SFA3_,`.S.IRTIC'IJ,',`,CH ARTIER tlR..C05,
<br /> DIVISION 2.f).(',Aa f PufRNIA fl,EALTIt ANI)SAFE"FY CODE)
<br /> .
<br /> Lx�re.e your Iso,:.,,of IhE;cALr,ai,,:an 006)US i s.;»adc Be-ate ,cant ricalbur t�tA.c?a is 6 .,t.cr .3&Wm ym,xsr°€z a .a§'li['Ataa.a, ,..r,hu a aA ca'3afzrit,
<br /> ReC kuraimi c h s:e 1K a,"v,:?:e o;that cad reit!€aan.w as laaaruly s v,t.,,,c;i'..c r.,c m 5 rvNmAT am 5„N `.{,_-4 ,pr t,•=a ser.%&c r t,be
<br /> ,tars as;x d in I=I ' 1 n BOIS win ca xrt ps < xas nemp from z z err we, to f c so retwto< fl if youdp nos
<br /> lrrav,,ata ouuiC_.' lh BOC,'yak if you have a"Y.Am"YardIngt3a, k M ex.junw,onse am we Ma..h ?ir,, d QUOasswwcc
<br /> to to iSCfI,ar 1.+ 9a`r"2oe ..W,aMs,.,4 loud 4 Lc,ra:tE.nwsa,buil lima LNvsimt,141 <lrrr fA 6„~a'7ca,Snspa,;:xrti,,CA IQ.. :..;1. !�
<br /> V Oat:I RC)a,Li_11 V;VF A s„NAN(AAI,. I"Ok MO R$).30 aA US 14 ON1.',0 6 .."C ( V"2711
<br /> ,tai)
<br /> OF 1111,1121 CHAPTER I( CALIFORNIA U',ODE'OF E (a,JAAg}t0NS)
<br /> identify 1h," s;.. ,,i bs aLa Owner Ras dlot Weawn ire r,t,.atinsd Be Adcraal and Swe astern 4 t 6 w_= t? sck.AA tum . t S I a(a nod sy
<br /> any I,=.,V or Sjue al,,€„y as as m as rao pt trWceau I STs ate exaunp;60rte th"t,ag.,a; sats tit.
<br /> VI.LEGAL Nty`i'lhtC;Ah1C)NAND lill,Lz'«CaADDRESS
<br /> Ch 1,ONE`'SOX fire de,addruss IItat will fe,us.;d foo BOTH LEGAL AND BILLING,NOTIFICATIONS,
<br /> TANK 43Y4`:'tiER OR AL;"s"I'sf3S ZED R'Ia'"RF,SI-',NTa l'IV:p 1s(")ST SIGN AND L AI �T, HE,IOR,',1 AS INDIC.�s ll 7I_I SI,a,£s:t;°;t ZM I
<br /> (e)t131 O TT11E E 23 CHAPTER APTER 1£s,CALIFORNIA CODE CS'n REGULATK S,]
<br /> Itx'S'TIlUMION !`ORTHE 1,OCALAGENCIES
<br /> Ile cow"y cow" a.,,..rasdk set nuri an s ars prvilem rxiiwd€tile&can be clbtaked by calling the Staw Board(1916)227-430:3, Ils,facility rc€r,r,$xer may
<br /> assigned by An}ilial aa,u nn honsve ,the ntazxdaermust,be numedlind ward canaaot contain any ail h betical'chara=eters,-31 we local agency I,Aefcm
<br /> Me Stme B"a d tis assurer vc facWt}xttaratbeq please karve it blank.
<br /> IT IS THE ESI;SI'ONSIMI.ITY 01"THE LOCAL ACE,NCY `I`ITAT INSPT C'I'S`lli FAC ILITy "I"C) VERIFY THE At:C URAcY ybl 1'111:
<br /> :Nl'C RAIAA'110N. TI RS AITLIC:A1 ON CA'i'v`NC)T BE PROC,I; SI_D IF T'FIE BBE (CCJC,'.`r"I INUMfH,,',R IS_NO }'"C(.LED IN. '111,11)CTAI..
<br /> AGENCY IS RE&PC)SS1I31.13 FOR♦•TyI{1 CC 1TaI.I~`1IO OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE,1 ORM"A1"AND ASSOCIATED'FORM VY)TO THE FOLLOWING ADDRESS. 111171 LOCAL A°sClmNC'.Y SHOULD
<br /> FZETAiti"1III;C)i'v GINA1I S AND I&RW'ARD THE YELLOWCOPIESTO THE FOLLOWING ADDRESS.°I`IE PINK COPY SHOULD BE
<br /> RETA1`slit)BY Tilt TANK OWNER.
<br /> STATE E OSer C ALI]FORNIri
<br /> STATE,,WATER RFS€U CES t:t3lti'['ROL BOARD
<br /> 00 S.Vd,k.,.t.l S,
<br /> DATA IxROCESSECS:CENIE12
<br /> P,O: BOX 527
<br /> PARANiou T,CA 90723
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