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<br /> INSTRICTIONS FOR COMPLETINGIkRM "A"
<br /> SEC I'ICIIN 2711 OFT=""I I,Ii 23,Cl IAi'IER 16,CALIFORNIA CODE,OF RECFUI,A"11ONS AND SECTIONS 25286,25287,AND 2:5289 OF C11APT'EI2
<br /> 6.7,DIVISION 20,CIAL11,O NIA HEALTH AIM)SAFETY C ODF.,REQUIRF(SWINERS TO APPLY FOR AN UST OPERATING G 1'ER:1 I .
<br /> I. One XzORY, "A shall be completed for all LW PERMIT CHANGES or any FACILI /SITE 33vIbC)I2MA'1ION CHA CzE&
<br /> 2 SUMMIT 6NLY ONE(T)FORM"A",for a I acility"ISa>�,regardless of the number of tanks located at the site.
<br /> 3, This form should be completed by either the l'l:atlaltl l APPLICla NT or the LOCAL AGENCY Cl2a"DT:Itt"akEOUieD TANK I;TSP Oft.
<br /> 4. Please type or print clearly all reyuestod infortuation.
<br /> 5. Use a hard point writing;instrument,you are making 3 copies.
<br /> Ct, Tank owner must submit a facility plot plait to the local agency as part of the applicatl tialhowIng the location of theJJSTs with respee to
<br /> buildings and litaadariarks(Section 2711 (a)(3),C;CRI.
<br /> 7. Tank owner must submit docurnentat.iou showing compliance with state financial responsibility reguirernen to,the local agency as part of the
<br /> application for petroleum US"1"s[Section 2711 (a)(11),CCRJ.
<br /> I"Op OF F'f RMt "aIIARK ONLY ONE ITEM"
<br /> EM"
<br /> Mark an(X)in the:box next to the item that best describes the reason the forte,is ba-ing completed,
<br /> 1. FACHITY/SITES INFORMATION ION&Al)I)t21.SS(41USt'IIF:COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> ;NOTE. Addrtss IyIC ST have a valid physical h aiion including city,state,and zip code.
<br /> 11.0,130X ARF',N'O AC Cim:P'I'AI3LE.
<br /> r
<br /> Include nearest cross street a€d naris of the operator.
<br /> 2. Phorte nutuber musib ave alt area code. lfd he might number is the same.,write"SAME,"E,"`tat proper location.
<br /> 3. Check ilia appropriate tx>x for TYPP',OF BUSINESS ESS OWItiERSHIP(ex.COIt1?O ATIO ,1NIDI IDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS,
<br /> 5. If Faci ity/Site is located withina an Indian rt servation or other Indians trust lands,check the box marked"YES".
<br /> En. hulicate lac NUMBER of'T`ANKS at this SJTE
<br /> 7.=Record the ET.A.11')#4 or write NONE"in the space provided,
<br /> 11. l'ROPI:RTY OWNER INFORMATION ea ADDRESS(MUST BE COMPLETED) �qy-�
<br /> Complete all item1�iii this section,urnlces all nems are the same as SITC:'IION 1,Ifthe sage,wzite"SATE AS Sfl'E3"aaroes this section. lie stare
<br /> to check PROPERTY CWSiRSIs1E' YPE box,
<br /> 111.TANK OWNER INFORMATION&ADDRESS(NMUST BE C:O4TI'l.F rEl))
<br /> Complete all items in this section,unless all kiern,s are the same as SECTION 1;If than same„write'SAME AS SII T"'acro,.,s this mctkni, Ear sure
<br /> to check TANK E}!av'I ERS TYI'E:box,
<br /> IV,130AIRD OF EQt.A LIZA`1`ICl4 US[ S TRAGI,t l li AC"CO3I IN'r?uilMBER(t'1LiS'T'I3F'C f7 il'E..Z"IF It.SEE ARTICLE n,CHAlt"I`ER,6, 5,
<br /> DIVISION 201;CALIFORNIA HEAL-1li AND SA 11`Y CODIF'.)
<br /> l tntcr vo"Ir Board of I qualara;ivtn(BOF)L, l ztomg z i`ee ac u`nt nusrnber uhi.h is rqu°rred before your pe neat application 4 a n .
<br /> , .pro ,:,�c d.
<br /> R i,tI1.1ziocn a4 ifli;I-rc BOI.v:ffl will v ceive a quarterly stwage fee r u it reg;onieng the 561.K)Er cert zit ,l r gs,lon Er due tare the
<br /> tn,A:ntatr csf ga.;,s. pia .,�f tr.y.c�tnrl.,�1`s. Ilac;13C)a wn,l sone perscntns.�xerrn}.=t i'rzxm pa)=aatg,cls >tc>�s�e,t`aw saarGi�3n__vlat a<<�2scx a z.;. (€y<b,tn r,ts rncai.
<br /> Ttlas<.�.t acc:;:..,_tt a".ati:Ls�.re,kttn tzzc;IiC3r or�f yeu hay; aray y¢nestioans tegarclirag,t}ne zcc cnr;;aennnlatn�>ras>p[c�as:aa[l asi=�I'st7?,as �z;(3 3'2°)Ciil`J c�z�c°r,ic
<br /> to tho 13(-)1;i,l the£cellon i ng,,<addi">ss lic"od c:`F.,tualsA Fan,Fuel'Faxes T)ivisit>nn,11.0.Box A 12,~79,S,aclwnerlLo,C A')a?. A ,0€01.
<br /> V, 'Pl;zl2OLl., ,:1, 1 1I f l� Ia1C[i 1'E) i1 L,l'1`Y (. [t.'S'rT33aC;C)Ll'1,LIEL)IzC)l 11PI `C{ LE",'°SIL.S1;,C7St.k`,Si,l, KfNs?/ a #) ;
<br /> Idc ...t , >tw its "t�cx.=3j �I bx [.;:,�aws;cr .t ,"'<>r oi> r<at r,int laic Eitag'tlss.I c acral arta.State ir.nnci,,a rc;;iomlbili y;eqtr ._,W,., ,t ".,1
<br /> .n, .,,
<br /> any:cdcnwt of Stateaq snEcy as laid as non p Toler rn USTart;excrinp hom this t xiats.Ctreaa%.
<br /> VI,LEGAL.',;TIFIC:ATION AND BILLING ADDRESS
<br /> Ch,c,k ONE BOXlor€N' addles that will ix awed for BOTH LF'GAL AND
<br /> TA"vKCJWNEOlkAt;'{'1IOR.13?I71k;1'ILf,S1Av'I:t`I'I4'1`StF7S"I"SSC'atiAtil)1).'4`I'E"T111,,Fi3134 As1—NDIC.,11ED, j a.i: z.:.l'.()"C":52711
<br /> (a)(13)OF'l I i T,£:'.'.3 CHAPTER 10,CALIFORNIA CODE OF IZEIGULATI NS.]
<br /> 1NSTRUCFlON 1"OR THE LOCAL r§GENCIES
<br /> The county an juiisdicticit numbers anrc predewrmizned and can be obtained by calling this Stats;9oarcl(916)"27 4 M3, the fac dki nurn>c r i-,oty°bis
<br /> assigned bk ,the,local'ag,cn:cy,ho�sevcc,iltis trazi net atrSt l FS rnumetical d earniaot sorttain aarny nll7}na4tctical c}nar<actc;rS. I(tSau toc.a3 :rn lsr*i r1;
<br /> 7 the State Board to aura the facility number,please leave it blank.
<br /> ITIS THE RESPONSIBILITY C7T'''l'Ilt�t LOCAL AGENCY THAT INSPECTS THE FACIIXFY TO VERIFY THE AC"("URAC'.Y OF THE
<br /> INFORMATION, THIS APPLICATION CA°NC:T FSE PROCESSEDIF THE BOF,ACC:<"3UN`T'N V),4Bl.,R IS:4OT lTILLF,T)INTHE 1,(,X-'Al,
<br /> AGENCY;S I I;SI'(}4 II3I.FI FOR THE, C"C NIPI.F:"IION OF THE "LOCAL AGENCY USE ONLY" ll' I'ORNNI'1"l'IO 13OAND FOR
<br /> FORWARDING ONI'FORM"A"AND ASSOCIATED ED T'C3RM"£3`(s)'TO THE FOLLOWING ADDRE SS. 'I III;LOCAL AGENCY SHOULD
<br /> Ia'EITAI$`Ilex,C?RK31,AIS AM)F RWARD THE YELLOW COPIES TO THE FOLLOWItiG ADDRESS.THE FINK COPY SHOULD BE
<br /> RETAINED III 'l I?l "AINK C)WNLit.
<br /> STATE OF CALIFORNIA
<br /> STATE `,ATET,RESOURCES CON-17ROL BOARD
<br /> C/O&W,E.EJ1,S,
<br /> DATA PROCESSLNG CENTER
<br /> PO.BOX 527
<br /> PARAMOUNT,CA 913723
<br /> 3:`13
<br /> FORD12091
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