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S FOR COMPLETING FORM "Alt
<br /> INSTRUCTION
<br /> SECTION2711 t)1:'1 l"I`I Ii 2:I, I'"a'T.;'Z 1 6,CALIIaOR21IA COD OF REGL;IMA T'I0NS A:SII)SEC'I'IC)IaS 25286,25287,AND 2528e3 OF CIIAP'TLR
<br /> ti.,,DIVISION 20,CALIFORNIA H ALT`sl AND SAFE Y,:C)I3r REQUIRE OWNERS TO APPLY FOR AN LIS'1'Ci1'IaRA`'I.\7G P},,R-M.F.
<br /> 1. One,FORM"A"shall be completed for all N EW PER.mrr C ukNGES or any F ACII TYISITE INFORTM kTIO CHANGES.
<br /> 2.
<br /> SOB-MITONLY ONFi(1)FORNA"rA"for a FacilityI`Sx;e,mllardless of the number of tanks located at the site,
<br /> 3. This form shoald be ecniple9ed by cith r tPac PERMIT APPLICANT or the LOCAL AGENCY UNDEa RGROUND TAINK I:CSI't>C f)R.
<br /> 4. Please type or print c:I,carly all rcquevtcd isn:Connation.
<br /> 5. Use a hard point writing instrument.,you are making 3 copies.
<br /> 6. 'Tank owner mustsubmit.a facility plot plan to the local agency as port of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8)„CCM:
<br /> 7. Tank.owner rnu-t submit docurnentatiom showing cOmf4iance with state financial responsibility requirements to the local agency as part of the
<br /> application for petrolcurn'UST's[Section 2711 (a)(l 1),CCR).
<br /> Mark an(X)fit the box next to the item that test describers the reason the form is being completed. '
<br /> I. F#ACIIXl7Y/SITE,INFORMATION&c ADDRESS(NIL`S s 3I:COMPLETED)
<br /> 1. Record name and addre,cs(physical locafion)of the undcrg ound tank(s).
<br /> NOTE: Address LvCGST have a valid physical location ineluding city,state,and zip code.
<br /> 11.0,BOX:!gUINIBE'RS ARI'',NO'I'ACCl,I'I Ar3I,,�,.,,.
<br /> Include near'-sir crass streetand nano of the operator,
<br /> 2. Phone number must have an area code, If the nigh number is the same.,write`SAME,"in proper location.
<br /> aation.
<br /> 3. Check the appropriate box for TYPE OF BUSTN ESS OWNEIfiS111P(ex,CORPORA'IT(7N,INNDIYIt)UAL,etc,).
<br /> 4. Check the;appropriate twos;for TYPE OF III.,SI II;.SS,
<br /> 5. If Facility'
<br /> !Site is located within an lndi:aea rescrv.atiori or oilier Indiana trust lands,check the hoax rnarkcd,"YES"
<br /> €i. Indicate tlac NUNI1t:F;R of`I`A.N S at this SI"IT,.
<br /> 7. Record ncc ET. A.31)#or writ„ NO E"in the space;provided
<br /> IL. PR{)PER I'Y OWNER UN OR IAT ION k J\1:)I) USS(;slt S TBEl COPLETT,D)
<br /> Complete all items in this section,unless;all i.csns a€c the same as SC' IO 1,If the saarne,write."SAME AS SITE`across this e cticn, He,sure
<br /> to check PROPERTY O°A':v LRSII[I'T`YIIE bcx.
<br /> 111,1 ANA t)WNE,R INf=ORMA?rC.l°o,&.ADDRIES`a(MUST BE COMPLETED)
<br /> Cron I It_tc all tt,.rrts in hlis z sct.ti>at<unlc. s ,:l steer,are.the sarrr as SI C"1`ON l;If the,satrac.,wrae"SAME AS I,.,1, across t;,is ,ce.=on, Be.sure
<br /> ita ,4..:k cikNKC}A4k"et.>CS i1;x.,ac>:<.
<br /> _
<br /> IV,130AR1)t)I1,,QtAL�:CATIR)N :iSI ' lOPI,A`at.;SwL°A..C_(P'-,- `TNL:MBER(:tiIUST11ECOMPSI.1F 11 SEF,A.tt'ICTT 5,CaIV!I1R`,'..'
<br /> I)IVI'SION 210,CALIFORNIA w€1`()z NIA tll.At,I a 4AN D SAFETY CODI`,)
<br /> fart r you Hoard of 11`Ia,l,r,:?.:u a(W)IzI 1 S x itnrag c i c account nurnbc r whidi k requil d Lx,forc,your rxt at .phcI� ,
<br /> g ,t� r1
<br /> Rcg _ tion w,.1.ific B011." a.il<,r.rr�:,Lia o.3 ,vil1 fe eive a elucartedy stw ag{e feu�au:n In reporting t c S0,(Jr! (6, l . <l r.,aae cka., tl. �
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<br /> ttt..nt .r<>I�,a?.at,s p,.s%.duaycaar_y,1.<. (1..,?iC)r.ua�Is,ocela�;r�unsax,.rr,14t[rts�tapai-uta,cE;uhtv�?aa},a.[„�:selrut,t.,.a,ar�,i..,,1, -�.. ,f�<.�.c�3sa
<br /> bav c,a€t .v"..it..antalnt.r wilt 0w BOF or at you i;avc any;questions retarding the.fcc or c-,oemphiorl,,please cart.,3a a>C �, , ._. 6.a,,,}{,�3r'I s
<br /> to tho,>t,L;.at a(.c.to 3c>.�inn aadai,ss 53�a.:�, Equ"alts ata€n,Fucl Taxis Division,11.0,Bo,- 942,8'79,S era,,c ,CA 941”, n,q
<br /> V f'I :fCC) I t"1I I`s( I IN A`C"IAL 16*.PONS€BI ITY alto ``I BEI€ON11'I 1 t"E"D FOR l'Ia'`ROT) h:
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