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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> Cr NE'^R LINS "SCC IONS:
<br /> SECTION2711 OF'l I"i L 2.3,C[xA'"I`I k M f.A IFORNIA,CODE OF R GUI. "I"SC3.NS AND SECTIONS 25286,25--187,AND 2.`+289 OF CHAPTER
<br /> 6,7,DIVISION 20,CALIFORNIA HFALTIE AND SAFETY a..ODE.-RE Ql I F OWNERS TO APPLY FOR AN UST C)I"saRr§.TENG PERMIT.
<br /> .Orse FORM"A"Shall be r:omptated for all NEW 1 ER-4IT CTIANGES'or a€syFACILITY/SITE INFORMATION C"HAIvCx.R.S.
<br /> 2. STs£3it r ONLY ONE(1)FOR,14"A"for a Facility/Si,c.,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by cithcx the PERK-11T APPLICANT or the LOCAL AGENCY UNDE.'RCROUND't`AN 1NTSPE(`TO .
<br /> 4.'Please typeor print clearly all re nested information.
<br /> S. Use a hard point writing instntment,you ata making 3 collies.
<br /> Er. Tank owner must submit,a facility plot plan to the local agency as part of the application.showing the;location of the T„7STc with respect to
<br /> buildings and landmarks,[Section 2711(a)(£?),CC RI.
<br /> 7. Tank owner trust submit documentation showing cozy Inliance withystate financial re'sponsibuity t quire ents to the local agency as part of the
<br /> application for lxltrolcum USTs[Section 2711(4)(11),CCRJ,
<br /> TOP OF FORM�"MARK ONLY ONE ITEINVt -
<br /> Mark an(R)in the,box next to the iters that est describes the reason the fonn Is being completed.
<br /> L FACILITY/SITE,
<br /> 1v tl'.SS(MUSTBE CNPLETEL)
<br /> 1. Record name and a<dkess(physical,
<br /> location)tion)of die underground tank(s).
<br /> NO°T`F: Address N UST have a valid physical location including city,state,and zip code,
<br /> 11.0.BOX N(iNIBElLS.SRI I, )T ACCEPTABLE-
<br /> Include
<br /> C EPTAilLE-Include ncartcsz etc"street aild spare of the Operator.
<br /> 1 Phone number niul;t have an area s csde.'If the.z,ight number is the s zzyac,evr tc"SAME"in proper location,
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.)._;
<br /> 4. Check the appropriate:box for TYPE OF I3L SINENS.
<br /> 5. If 1 acility;Sitc is located within an h.diytl rc c fv atiott orother lsadian trust lads,check the box marked"YES"
<br /> fs. Indicate the NUMBER ofTANKS KS at this SFFE.
<br /> 7, Record the fC.I',A.IL#ear write,"NONE"in thllspace l:mvicicd.
<br /> It.
<br /> Complete,all iterns in th.4 sc.ccita a,a..t s,all itc-ms<arc the sarne as,SS C.,'110N 7;If the worse,satin*"Sed III AS SITE"E"acro, ,;this section, Besure
<br /> to chEccL l3itc`yc''RTY 0WNl1RSI s_t''l Y N`.xaza.
<br /> 111.TANK C)yg`NER I:h;taORNIA,"i('), &A,7Ili ,,4£s,s,I ' t'111:C:tlMlal_.l`.."1ED)
<br /> Complete all€wnla itt this Section,unlesa ail ilems are the same as SECTION IO t;If the,sante,a rac`SAME,AS Sz(s^.'aacro>>);this°ection, Besure
<br /> to cbt%kTANK OW NE IRSTYPE box,
<br /> IV,BOARD OF 1,QUAIAZATIONLS i.`s'CORAGI,FEI",ACCOUNT NUMBER(MUST BE CON11'LETI,,,D.SET A11 iTC:"Ll.5,C'HAl"�ER 6,-7's,
<br /> DIVISION 20,C;tLI rORMA ill'z.hl,hl{,�� 1.)S, ilw'1'Y E.)
<br /> E'nt,r yourr Board of 1 }a.alas.a.i«cs(11,111":)US a stt?:agc fee account number svhiQh is rrtluired tsrforz your honnit ahpkc.atj�.,,c earl be p oc'�<excl
<br /> Rc .l,a,ioll 1 Y _1 g
<br /> .i.�r,t!ac 11,(>C i.ii?ur,�a;..a t;t.as a;3aa tua1�r..c�etvc a c caner storax,e fee return nt ret vos�ttta into;4W)06 r P,;rt;a1 , +'r i;.a.l sa.fc.°da.€ a3at tele
<br /> natnbcro" Telae,d,in yourl,S!'s.,Ili.,130G Will cod:;arsons excalpt firorn payin"'!tli;staarage l e so souls., will S3ot,!A,' 1f you donot
<br /> Tfas c.all.,ecea,attt rutrmftc.r\.h1;ala.,lif)l or if you have away questions regarding t e two or cm-im 7tions,plcaso call ill,131 t.,<a 9'6 _.29069 r„i z IU
<br /> to the faC it.at the,foiloa, g ltd,h-ss llo—d of Lflsa.aliZali0ns Fuc?Taxes Division,l'.Cl. Box 942K79, hsw=a:asetaSas,CA 912 ,-',;)a:a.
<br /> V, 1aL.? J .1. ,:1(. 1 T:A.1Nf:`IrCL IZ,: I'C} 4aISl lI'Y 1L.5"f 3I:C€? 'fl'hl,II?FOR 1'1:,:d C}i.1"`at4 USTs,tJ 1. lti,s,t.":iC)\s t +.)°,r.
<br /> x ,INNS,)
<br /> Icacr t,, ll-lo t> ,.a_ lkx1 su"b" t; e, vmet a.., car€p Fater,nl the 1 cd srai and Slat,-5,.,,anciea k ..�,.,Ri3!,.a,y ,..y .�. �.; .? r: ,....�4
<br /> any 1 edvl a of St atw owcney as tscll a,non pctloie,fn L S'is ale caentia.from this t,ellla.crncnt.
<br /> VL T htiht. t3'aitalC,.1T'it AND LULLING ADDRESS
<br /> C hcck ONE 13OX h)r the adkhcss twat v ill be uscd for 130111 1.1XIA1 AND T`lR1 NG NO WIC A l IONS.
<br /> TANK(Al %ill:R OR x'tC;l`[iORIZI;ZTR EPRE IlN IrlTIVE=,111US ''ST(s°S AND I`E IR IF'FO ZNI AS INDIC.l ED,
<br /> (a)(l3)C3E'"I[i 1.11'?sE.II.'sI'"1 EE 1�;�'AL..OI�NL1 CC311 CIt'1tEC1Cl.a4"E 1C1Ns.)
<br /> LNSTRUC 11ON 10,1 Till,,LOCAL AGENCIES
<br /> 1f S
<br /> ,and Carl be obtained by calling the Stats;Board 0A61 22-74-kill, 1 r o-nix a g'l ay be
<br /> assigned by Ln,.local<agcncy;hoaa oybr,th...s..libor mostbe tlurnedcal aid cannot contains any alphabetical chary lers> It ah l<><.al c}hr<a#care`
<br /> the State I3€:t,id to assigat th;facility number,please leave it blank.
<br /> I"i"''IS THE" RESPONSIBILITY OF'TIII^. LOCAL AGENCY THAT TNSP C T,13 THE FACITATY I'D VERIFY TTIFI' ACCURACY OF`I'11F,
<br /> INFOR-%IA ION. THIS AIIJILIC ATION 4'ANNOT BE PRO C">SSED IF THEBOE ACCOUNT NLJYABIIR IS NOT 1°SI.I:ED IN. `11FI L L
<br /> AGiIiNCY IS RF"SPONSHILE FOR THE, C"C3's`11111:"1ION OF THE "I,C3CAL AGENCY USE ONLY` INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED D FORM°"13"(s)"TO THE FOLLOWINGS ADDRESS,SS. THE:LOCAL;AGENCY SHOULD
<br /> RETAINTHE 0RJ(ITNAt S AND FORW ARD TME YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> R.l"h itility i3 '"d Lila'TANK OWNLR.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> 'CA)
<br /> DATA I'IOCIvS,4"LNrG CE N1"
<br /> P,O,I3OX 527
<br /> PARAMOUNT,CA 90723-
<br /> FOR012ORI
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