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UNSTRACTIONS FOR COMPLETING ARM "Alf
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 O 'I I I I.I 2:3,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,,CALIFORNIA HrALXII AND SAFETY CODE REQUIRE OWNERSTO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One:MORIN"A"shall Ise completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> S.
<br /> 2, SUBMITONLY C)1`a'LY ON (1)FC>1dM"A"for a Facility/Site,'ml ardless of the;nearrbet of tanks located at the site.
<br /> 3, This.cant should be completed by either the PERIN11 r APPLICANT or the LOCAL ACFTINC Y UNDE-'R ROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard paint writing instrument,you are making 3 copies.
<br /> Ct. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the-US`T's with aspect to
<br /> buildings and Iaan&narks[Section 2721 (a)(8),CC;II:`l.
<br /> 7. Tank owner must submit documentation-,howing con)pliance with state financial responsibility requirements tta the local agency as part of the
<br /> application for jactrolcurn USTs[Section 2721(a)(11),CCRJ
<br /> TOP OF FORM: MARFC ONLY ONE i(`1s`W.
<br /> Mark an(X)in the box next to the ucm that lx st descrilxss the reason the form;.s being completed.
<br /> I. FACILI z YSSI'I`'I'aFOR'sTATIO AI)DRFSS(MuSl,TII;C".C3MIrl.ETED)
<br /> f, Record naame;and addtcss(physical loc,,nitsn)of the Underground tank(s).
<br /> NOTI`. Address:s UST§rano a saltd physical location melliding city,sttiatc,and aal ccalc:
<br /> 11,0.BOX IsIUNIBI;RSART YC31 At C..rul�l,�LTat..
<br /> include nearest crass street aau na,rac,of the operator.
<br /> 1 Phone nt lnbcr tnua t have ata area code, :If the;night number'is the<arne,write"SAME"E"in properlocation.
<br /> 3. Check the appropriate box forTYPE,OF IILSEN SS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.). `
<br /> 4. Check the appropriate box for TYPE OF}31.SINh"SS.
<br /> S. If Faeiltty.f ae is located within an Indian resenation of Other Indian trust lands,check the box marked"YE.S".
<br /> 6. Indicate the NUMBER ofTANKS;at this`IITF.'.
<br /> 7, Record the I-P. A.Its#or writs NONE"in the,spaactlplovidcd.
<br /> 11. F'SZC)PERTY C:7WNFR I'*l=+Jl$M.';'I IONI&ADDRESS CC)M'T.ETE D)
<br /> Complete all items ill fh� s(cction,rau'ese all items arc:the;a<trrrC as SI C I`ON 1;If the Santo,writ "SAMIT.AS SITE`a�r.4:,this sv ti<x)> lac sure
<br /> to check PROPERTY OWNI RSI IIP"T Y III.ix)x, '
<br /> TIT TAMC OWNER INFORMATION&A.)1)RI`35(Y1[.S l"BE C{.)41PLE.."I'I:1))
<br /> C OTTI;lctc all itenIS ill tflks Sec;ti n,Unless all to ms are tote same as SECTION 1 If'thc,same,write"SAME AS Sar 5:;"°across d6s sac ir.ra. Rt","'we
<br /> to a-,c.k,rANh:OWy NE'RS TYlrE hux.
<br /> IV,BOA'.Zl)OF tz(;t(.AI_IIATION I iS a S ORA{,l.r l.ls.lt.,C t)L�S �L:47F31s12(TAUS I I3F.f:OMPLE-I .D.SEE ARTICLE 5,C.Tt;a VIFFIR 6.5,
<br /> DIVISION 2i),.C,rtl.lFC)RNIA HEALTH AND SAFI`TY CC}llE.)
<br /> Elmcr your Hoard of (I'l0l')'C„ t stuaagc fee account number which is requik cd hr.4or yourpennit ap plicafil n, ,an NL,,Ito,c,,ed.
<br /> Itcsp>€.t,�rttr ri av>.it 01c BOH w z c.,v.w recesve a e}utsrto:rly stmago'fee rem in reporting t`ra.Stl.Y06(,-r)?,l toot alt.€ ,as.fist
<br /> rluTnbc,rof Fa..rt) },aHc 4d ill
<br /> ,tit,,
<br /> t.<�E�atc .3CJL ta,tltc iullu 3..tt <sdcz...,�<3ca�r�l_:E�ds<alixatscrn,;I uca Iaxes 1)ivisatati,P.0}.t>ctx 9 t?9s(i,S.er;aa.,>,,,[,,.€':?`} ,. , l>1.
<br /> V. iyl:"TItC)LEU-N1'JS t'HN NC'I,1t.RESPONSIBILITY tNIUS`l BE COAIPIII'[TED FOR 11I:'E dtOLE'i N,UST,()S s,)', I;r.,t.
<br /> OFTh:(i1.L_,t::1t.Li'ii.R16,CALI1OIRNIAC;4?i i f). LC`ziT<Y`F!ONS,j
<br /> any .a;,,rldy as well as nett p trcriet..n L I I_s arc CXen"pt fr€,rot th?.icquirtrrtc.t)t.
<br /> VI.LEGAL NOI'IFICA"D I` AND BILLING ADDRESS
<br /> Check ON Ile X fo3 the"at,44caa tbai v;ill be usecifor BOTH$t',GA1,AND BILIANG NOTIFIC A'CTONS,
<br /> TANK OWNER OR f'IC;'1`HORT/1IT) US"TSIGNI AND L>,S"I`l:"1"I[II TaC)1ZM AS IN[ACA'1M1). J ?.i`S..( 10,'S''r/t i
<br /> (a}(113)C)F'"I I I`Lfi'33'C.11 CHAPTER doff;CALIFORNIA CODE OF REGULATIONS.)
<br /> es.)
<br /> INSI12U(7I'10N 1OR TIN',l,.()CAI-AC,ENCIFS
<br /> The C U N an ilxriSdic,sont nWn x rs aacc I>t..c;utca,a#ac and can be obtained by calling the,State Board(}16)"'22, 4303, S he,,._ai , mmibcr n,<a N
<br /> asnigncd by otc,locala1 y,However,this naaatber arsust be nurnrlrlcal and cannot contain any alphabetica'charactem it`thu to a1.gtmy J)""fors
<br /> the State I3o atd to assign the facility number,please leave it blank,
<br /> IT FS T1112 RtsSPONSIIBILITY OF'1`1113. LOCAL AGENCY THAT INSPZCTS THE FACILITY '10 y'l R[FY`1HE AC l.': `RAC',$OF 114p
<br /> T:NF ORMA"1;1C).`e. TI HS APPLICATION CA:ti SOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOTFILLED LED IN, '3ITls LOCAL
<br /> AC"E.NCY IS RE'Si'C3I Si13I..E FOR THE COMPLETION' OF"KITTS "LOCAL AGENCY USE ONLY" INFOR'4TATION I3OX:AND FOR
<br /> Ir(:)R4t.',1RDING ONE TrC)RM"A"AND ASSOC:I,Z"I`FD FORM"B"(s)TO THE Ft"C)Ll>OWLYCa AI:11 RE'SS. THE LOCAL AGENCY SFFC)U11)
<br /> RE AIN THE C?RK31NALS A\I)FORWARDTHE HE YELLOW COPIES TO THE FOLLOWING ADDRESS,THE PINK COPY SHOULD BE,
<br /> RETAINE'D BY]HE TANK OWNLR,
<br /> STATE OF CALIFORNIA
<br /> "A-ITE RESOURCES CC)N"I`ROL BOARD
<br /> CIO S:4e E.E.P,S.
<br /> DATA PROCESSING CENTER
<br /> P.OBOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3r9s
<br /> FOP412ORI
<br />
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