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INSTRUCTIONS FOR COMPLE'rING, FORM "A"
<br /> GENERAL.,INKS 3'RUC'3'lONS:
<br /> SECTION 271;Of "I'1-1'LF.23,CHAPTE'II 16,CALIFC)R°CI,A CODE,OF RT.,',(;U-1A1I0NS AND SECTIONS 295�286,25267,AND 25289 OF CHAPTER
<br /> 6,7,DIVISION 20,CALIFORNIA HEALTH AND SAFT,!'YCODE ODE ICa-.0 DIRE OWNERS TO APPLY FOR A:'e USI`OPERATING I'IJCMI°1`.
<br /> 1. One I'C)RM A"t,z%11€k w::ras%i:inti for a]: E;%, P1,; 1,:!T CIIANCII"S ox any FAC`I1,ITYiSITE INFORM ATION CHANGES.
<br /> 2, SUBIMIT ONLY ONE 0,1.'CRM"A`fo a Facilii, regardless of the naznber of ta=nks locaicd at the site.
<br /> 3. This form shi,aid be ccgnp,t t,rd by Ether the tai;is', `l'ARI'3LICAANT or the LC)€°AL,AGENCY UM) RCsRCF.N')TANK 1.;N'PEZCTOR,
<br /> 4. Please type car ptint&!arl .,"n Quvw,,d
<br /> 5. Use a hard print writingtt a�a f,mt.,you are rna i=,: olaes,
<br /> 6. Tank owner mu"submit a fa; l it.y Plat Puts to the 1 I agency as pare of the applia ation showing the location of the USTs with ret pcct to
<br /> buildings and landmarks[&,ction 2711(a)(8),CC:RI,
<br /> 7. Tank ow nar must.sufsmn doctatttcntaiion showing comp fiance with stale financial responsibility r Rttirmem as the local agency as part of the-
<br /> appli.c.a&n for Ixsaofs"um US'Is(Seem:.2717 („a)(11),CCRJ,
<br /> TOP OF}<<?RNC"IMARKONLY ONE,I'IEM"
<br /> N9 ark an(X)in the box.twxt to the itc.;ni that Ex st dc-scribe,zlic reason the fonn is being aornplcivd.
<br /> I. FACILITY/S1'1'F a:4IsC)1CM:1'f`IO &A'.)f,)1ZC SS(MUST BE COMPIA.,Tm))
<br /> I, Rocond name and ajdi ss(physical lcx:aiion)of the rand'i'k>rotEnd tanks).
<br /> NOT'r. Address lb iJS"I'have a valid physical l xaticm including city,state.and zap coria;.
<br /> PO,BOX 1°ti't' BI.,.bS .R.--4('}T ACC'E.P A-ATiLE,
<br /> Imlodc tx..araar cro>s st _ ,nd r ,°tt opc.rau,r.
<br /> 2, Phone ss,arntac._r-,.mast h i r. aTr arFza ,::l.< i..,..;.n.rttlx.€ ,
<br /> 3. C'heca €pair,ln1_,�] ,(sa:'; 0a i F , .. �°<` ,
<br /> <st3?a. i . s 4:'17C_l ,1UNDIVIf?�UAL,rtc),
<br /> 4, Che,* f , .:i>ate to�
<br /> ',-A imi trnzit last is,cheek iEe box markets"YES'
<br /> C ra„It.c xI_is<,r__ _, I F .,. .,, „wli;'c ISAN€F ASi SI:I E`a..tt>vs tE,r, z.z�.zsm. I?t.suye
<br /> "'PE
<br /> 1;If"rite Hairt<C,w :.�. ?;AME AS t STI,;"a,< �s.l,,i ..:.Sari. ka.,_=..r�:
<br /> SHOULD
<br /> Li_t 1x`C:£ai. .> .�, . _ 3 K£Sti. f,E PINK COPY Sf OUTI)BE
<br /> FOROMR1
<br />
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