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INSTRUCTIONS "Alf
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 271101; ,I''I.E 23,C'HAP TEIR 16,CALIFORNIA CODE OFREGULATIONS LATIONS APED SECTIONS S 25286,25287,AND 25289 OF(-,11AI'TEk
<br />' 63,DIVISION 20,CALIFORNIA HEALTH AND SAFI.,,TY CODE RLQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. {:Arc FORM,,„A"shall bs cornpleted for all NEW P£ERYaUT CHANGaE?S or airy FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(l)FORM„A"for a Facffityl site,regardless of the number of tanks located at the site.
<br /> 3. This forret Should be completed by either the PEANUT APPLICANT or the LOCAL AGENCY UNDERGROUND T"AINK INSPECTOR,
<br /> 4. Please type or print clearly,aE ra yta st A infornustion.
<br /> 5, Use a hard plain writing inss'urnsri ,you arco making 2�Ct ne_s.
<br /> 6" Tank owner must submit a gd-acy as part of the application sho-wing the location of the US is withrospeettra
<br /> buildings and tandem ks[Section`'.iaCCRI, Y
<br /> 7, Tank ovine must subinit documentation Showing state financial r ponsih li€y the'local agency as pare ofdie
<br /> applicationfor Isitr k"nrouSTs(Segtiou2711"(a.},Ti),ccilt.f.
<br /> TOPOF IaORNI°"MARK ONLY ONEITEM"
<br /> ,Mark ris(7t)in the box next to the,itent that belt describes dec reason the,from is being cornpleted.
<br /> I. FAC7It.ITY/S'I'E ISI°ORMA'IION&AT3I3 I,SS(.I�lc 'I LlE<'£1-\�1PI-EIED
<br /> 1. Record nacre and add .ss(phy:,vll'loratt«n)of the underground hink(s),
<br /> NOTE Address M ST have a val:d p r`slca,location incinding city,state,and zip code.
<br /> P.O.BOX NUTM13E'RS AR13`CCF["ACCEI"I'ABLE
<br /> Include nearest crass street and rsacrtc 01`111C operatcsr,
<br /> 1 Phone,number must have an arrei code. If the rrgfa.slumber as the ser U,write"SAME"in proper location.
<br /> ttar.
<br /> 3. Check the appropriate box for TY S'h OF BUSINESS t WNHIICS1111?(ex,CORPORATION,PORATION,I2wfDIVIDL;AL,etc.).
<br /> 4, Check tiro appropriaor Erol for TYPE'fll <3T'SI-NESS.
<br /> S. If F acility�,eSite vs laeato.ol Within an Indianraserrataoe ser ctl�er hnd:ars tratst.sands,check the i�ox rrzarkod"Y'ES,,.
<br /> 6, <ndicaiethe,'suy;.BTL tof`IANKS at this SITE. t
<br /> 7. Rcscord the FT,A,ll.)1,or wore `NON in tlro spaiee provided,
<br /> IL PROPERTY O NT'R,INN; RN1A'i ION r DIDRESS GMU'S'S`BE t;OMPLETFD)
<br /> Complete all bums in this scctr>nr uld ss all nexc;s are the Sallie as SI_C DON I;If the Since,wriie"SAME AS SITE"across this Section, Be sure
<br /> to check T"ROPE,RI'Y Cl3a NERST11I'TYPE UNA,
<br /> IIT,'1 ANA t9yY"NER INIr(3iYJlA' IO,,;d ADDRESS
<br /> Cc,ti;fueze all.tees in.iii,Section,unl s's all lac cels art,,the stini as SECTION 1,of tiro tante,wrhe SAyMI`3 AS SITE ac.rross this section, Be,stire
<br /> to check TANK
<br /> IV,I3ClARD 01:FQ?U. 1 JZA 1 ON US 1`SC)IC yG I FE AC4:°01,, T \C.f 4f13T.R(MUST BE CC3MT'LEIF',11 SEI.ATI-i"ICI.I 5,C II AP ITIR 6,75,
<br /> DIVISION 2t),CAI,I C'tw\i;iIii,lC:?via,7
<br /> l.r«tIt„urrf,._.dof..y ...., !,�+ri ,cs 'sto .axe rt.v;�"�uaart,tunsezv<hi s Bart,ut>>.edt�Itarey,aearlxrnritalsla3ac�,ac;.: a:a,b,a;�e:co".:orf. '
<br /> ?t s e�e.Ae„ww�t(a;lac fie,?:._ia..,r, s,r t a.,t y:c,r ww�al rWerwiva .a vTt,arierlY s srat,e,f�c e�.parr.ve r€^�st'fs?u3�=Ala�(}.tx?Csti)a'r �'..j sear 1. ,,"t,�e��_�E�,.a�a h
<br /> n�atr�lzr o: .I o,.,n „cd In y.sr a a;1,ol, persr>nc cxamiae I >7n t>ayi r,fit,,Stsnagc..tc,<,i, %V.,' .,, h� •.°r
<br /> . . , 11 €a.js not
<br /> h, o.
<br /> _ ,a ac,,�,t,1a.a_bc ,Mita?_., 1,0Eor.z you I =c lay di"o It"t fec,or x.,rEap�isaar.,aac4sa,CaU iho BOI3 2t S1'16 322--k-,69
<br /> tc the.SC; at the follow;� add. ,� lion d of E;e'lar.�hr, tiaga,r Liel Taxes 1)tysioa,PJ'), Box 4A28719, ..e€maty Baa,{�A t<2,1-f;OI,
<br /> V. $'1`'I ICC}I2, , T c .F a`I.x, v;'l � 3 t.t.1i { is i Bt"C OM"Ill,F CL D FOR FE I I?f.fl>'Ft m EaSTs,ONLY, l-'H'ii�?1£,t."S 2711{aA
<br /> C11°TFI1,(,b3,C TG,t, b` as 16,CALe,0RNItYi_;f Dl',0 lE REO a;LATIONS,)
<br /> Idectify the saretF i( j a sco by the oo,nc nd!or opconor,in,etxattsag the Federal and Stage.iimn6al rospoaa»i sty fu,pi,n)_t nls',t i;'s wd by
<br /> ar v}c-iera,or State:ag ncy as well as za<.+n Isc.arois,um USTI;aro excxrpt front this roctuirernent. �.
<br /> VP.LEGAL NC'p�!flIC.,Ay�ION AND B11 l„AG ADDRESS q`�'
<br /> Check O'NI"BOX f €, a I.twSS ih al a ll be isud for BOT IT LEGAL ND I3ILLI'G NOI!FfCA'11',t ,
<br /> TANK CAVNIFR OR A Ti1C a.C.,,L)i2 t sCLSE °I'A T`IVI,YII'ST„`',I(`AND D ATF, t I IE I"(3RM AS INDICA fl`J). S 1:1 S€C .iON`s 2711
<br /> (a)(13)C,I. 1.H,F,,23 C 1aAP I t :C 16,C .'ILH,aiJl NIA C.',t)DE OP RE CFl;LA T IONS.]
<br /> INI S'IRIUC`a IO FOR 1-11U,LOCAL A a`2;C;IES
<br /> The count} ar,f=.a6sdi to rr vurr.,xoas arc: and call l be-obtained by calling Lire"Stant"Board(n16)2.27-4301 '!'Ile Fe
<br /> assigned bw the local cS:hoe w: cy,this number traust be nuttterical ince{cannot contain any ti' h.,baiacal characters, a tho x seal agency l,rcfc la
<br /> the State Board tri 2y�.t re the f 4,ilii y n-a oer,pie ase leave it hfarak.
<br /> IT IS ili. ..T.°i'() S.I I'1"1 Y' OFTHF'`F' LOCAL AGENCY"I"1IA 12 SPECTS "T'TIE FACILITY TO VERIFY THE A C i.%RA(.,Y OF ,ITIS,
<br /> INFOR3IA I ION, I HIS N ILICA71`0N CANNOT 13F PROCESSED IFTHE BOE',ACCOUNT NU'MBDI IS NOTFILLEDIN, THE LOCAL
<br /> AGENCY IS RF S"O<SI ILE FOR THF' C O'vlI T.,E,'TlO C.11"THE "LOC"fel.,AGENCY USE' ONLY" INFORMATION BOX AND FOR
<br /> I'C,aIZw4`ARDING ONE a OR.w< A"AN'D ASSOCIATED F°OPM"B"(s)TO THE FOLLOWING ADDRESS. ME LOCAL AGENCY SHPULD
<br /> RETAIN THE 01UGI"iAi.S AND FORWARD THE-YELLOW C:OPIFS TO THE FOLI.C7WLNG ADDR6 SS,7I`11E RINK COPYSHOULD BE
<br /> IZI TAT\I.D BY Till. "1'A14R C)WNEIR.
<br /> S'I ATE OF CALIFORNIA
<br /> wISTA"i l;YV1"li}t ri E SC3t RCI s CONTROL I3C3AFtI7
<br /> CIO S.W1,EJI'S.
<br /> DATA PROCESSING CENTER'
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 93
<br /> FOROmRi
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