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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SE,CTION 2711 C)i `L'I'I'I.I 23,CHAPTI,R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286„25287,AND 2,5289 OF c1iAPTER
<br /> 6.7,DIVISION 26,Cry LIFOR'IA HEALTH AND SAFETY CODE;REQUIRE OWNE:RS TO APPLY FOR N UST OPERATEIG PERMIT.
<br /> 1. One IaORNI"A"shall be complcted for all N FW PERMIT 4_.i CANOES or any FAC Y/SIT E T FCIR ATLON CHANGES,
<br /> 2, SUBMIT ONLY ONE(t)FORM"A"for a Facility/Site,rcilardless of the number of tanks located at the site.,
<br /> 3. This form should be ccrnpleted by either the PERMIT APPLICA 'For the LOCAL AGENCY UNDERGROUND TANK 1NSPE(70R.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing ittstrutnent,you are making 3 sc,;ics.
<br /> 6. Tank owner must sttmnit a facility part plan to the local`akancy as part of the application showing the location of the Us i s with respect to
<br /> building-,and landmark,[S-cxion 271 l(a)(8),CCR).
<br /> 7. Tank owner merest.submit docurnentation showing compl.ar cf1l with sty financial responsibility requt ms to the local agency as Part of the
<br /> application for petroleum USTs I Section 2711:(a-)(!1),
<br /> hOPOF F ORIM:" AFC£C ONLY ONE,III-Ns"
<br /> I3lark an(?C)in the box next to the itern that best describes the rcacon the form is being completed.
<br /> L FAC'ILITY'ISTFEINFOR-'sIATIO YzADDRESS(MUSTB COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> TOTE: Address MUST have a valid physical location including city,state,and zip axle.
<br /> P.O.BOA NUMBERS ARIE NOT ACCEP'T'ABLE.
<br /> Include nearest cross street and name of the operator,
<br /> 2. Phone number own haus aro area code. Ifthe rugal number is thesame,write"SAME"in proper location.
<br /> 3. Check the appropriate box forTYPE,OF BUSINESS OWNERSHIP(ex.CORPORATION,I\'DIVIDUAL.,etc.).
<br /> 4, Check the appropriate box for TYPE Cala BUST--NESS_
<br /> 5. If Facility,Sitc is hlcme.d within an Indian reservation or otherIndian trust lands,check the box marked"YIES".
<br /> 6.,Indicate chc NUMBER of`IATKS at t t s SITE.
<br /> 7. R ccool the 1,P. A, )4 or write `veONEI in the spare.provided.
<br /> Ii. PROPERTY OWN13,R INFORMA110N 4i ADDRESS(MUST BECOMPL.ET D)
<br /> Carnplcte all'stcrnr in Haas seciion,cr 0css all terns are;dre same as SECTION 1;If the same,write"SAME'As srl':°across this aectnIxt. Be scare
<br /> to check PROP EWI'Y OWNEPSHI P TY P E box,
<br /> 111.TANK K 4}WNI--.R INFORMATION&ADDRESS(aNIUSI BE C ONIPLE1 D)
<br /> C"oinpletc ail Acme in this st cfion,unless,aH ii.a is arc this same as SEC 11C)N 1;If the same,write"SAME AS SITT—across thk section, Be sure
<br /> to check TANK O `stEtCS T"I I;Nox:
<br /> IVBOARD O l:QUAI I ATION L 5I' 'i t311, Cr.:Iat%1 ACCOUNT I`:tiL MBEI (MUST BE COMPLETED,SEE ARTICLI,5,CII.tIaI`FR 6351
<br /> DIVISION 20,CALIFORNIA III. L i ii AND SAFE IFY CONF,)
<br /> F;rtter your lio'ltd of k.<luavax.alion(1301"),US I'siorage fee account nurnber which as required before your Fx rmit a:a pli'a..<;a Can be rnocs.se 1,
<br /> R �t=,tion 4t ila itis 13(1€'wili ux)sure that you will receives t u<arterl-Storage fee Tenant in reportingpthe S OAs)6 wili11� `.,crallon fc, ducondle
<br /> r.t:raLx.,o°'1.,.}0rsF' s..dansout 'as. Il;c°3C)i.will code persons excrra}atfrom paying the stc3aaW;c.fee s,,r..�U:,=s , .lE<uai>v 110"}.>u d'onru
<br /> have aro ae,owltl uiaar.lrut wiul the I O'E c a If'lou have art}questions r galding the fee of exc ioptions,plcdeo 4.a.I ih,,1a>i,a,1 a.,.-9,669 car �:rtta
<br /> r
<br /> to the:30F at the followr l:e actt,r„ss Bo .,o1!,'qu.al:vadon;Fuel I"axcs Division,l',O.Box 9,42979,S„.r`n, aa(u,CA 9,12
<br /> S. 1'1:'1'1 C.}I_a.1 1,t, E :`(_`r E C;,.=<:,a 1.>t'?"}a
<br /> c _ z . , . 1 =.w"1 aEvs 271 ,sfcE'( . , .
<br /> OFl. ie`23,
<br /> C 1..r1'`I'3..1 1`_ C.�s,LI (?IZNIA C;C)i�al.C>aa Rl'(L;LA'I IONS.)
<br /> Ia.ra,Cy the.n.elhtxs`ar used by L"111 owner owns l arld/or r jx,ator,�n mectrag thea Fedcral and Slam finari,Cal,c popsibill v r r. S 's ovrcd by
<br /> Fcd,r:a'bra Stat€:;agc1ley as v-ell as n n lll'ool a,n US'I s a exempt trete this rt quirensent.
<br /> VI.LI?,CiAL NO'NFICA`lilON AN'D BILLING AI DRESS
<br /> Check O'i,'BOX for the,addic� ,!hat vi11 ha used for BOTH LEGAL.AND BILLING NOI'H`ICA'FI)NS,
<br /> 'TANK OWNER OR AI,'ITSt,a?tiU i l)E I..?'1taESE "1'z "`Fy'I;MUST SIGN AND DATE HE'Tat:RM AS INDICA I I.1). ,.i:`EC t O S 27.11
<br /> INSTRUCTION FOR fi_Lt LOC l-,A(',1---NCIES
<br /> The couroy an jurisdiction numbers are po deter neled and can he obtained by calling the State Board(916)227-4301 The Ta.t,..}ilei iberniav Ec
<br /> assigned by tate local agency;ho%a ever,tie's number must've rt encricai and cannot contain any a E ,ab„tical clrar:ai:.ters. If tie local agency prefers
<br /> the Stale Roarer to assign dle facility number,please leave it blank,
<br /> IF is' ful-, RESPONSIBILITY OFTHE LOC",'eI:AGENC;Y "1"€IAT INSPEC"T'S THE FACILrI'Y TO TERTFY THE ACCURACY OF THE
<br /> I'41rORNIA'e-it);o. THIS,APPLICATION CANNOT BE PROCESSED IF TITS BOE ACCOUNT Nu,,11B6EK 1- NOT F11..T.;t,I)IN, 'I'€ilE;LOCAL
<br /> AGENCY IS RI'Sa'{.3\SHILE FOR TIDE CONI#LlEi'iION OF THE "LOCAL AGENCY USE ONLY" I: ta(2R IATION BOX AND FOR
<br /> FORWARDING ONE('C,kRM"A"AND ASSOCIATED FORM 13"(s)TC?'S`HE FOL.LOWI`G ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RL IA1.a I III;<11L1CxI.SA1 S AND FORWARD THE YELLOW COPIES TO TIIE FOLLOWING ADDRESS.`ME PINK COPY SHOULD BE
<br /> RIa hAIN EI)13Y T1IIi TANK OWNER.
<br /> S'I A'I`L.,C>F CAI.IttORNIA
<br /> STATEWATER RESOURCES CONTROL BOARD
<br /> CIO&W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> ER
<br /> P,O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3'93
<br /> FORD12ORI
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