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INs,rRUC,rIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> S1,CTIC)N 2711 CJI'14,,1"S E 2`1,C:II AI TER 16,CALIFORNIA COD,OF REGULATIONS S AND SECTIONS 25286,25287,AND 25Z99 f)I APTER
<br /> 63,DIVISION 20,CALIFORNIA DE AL"TH NNID SAFETY CObr,,RFEQUIRT CiWNT,'.RS"rO APPLY FOR AN UST 01ILRA` G`PER .
<br /> L € nc.GIs.AT"A`shad Ex�co .r aC dd fol ah NNE L'iaR:o-3IT CHANG&S car any FACILITY/SITE E''rORh,lxJION'a.',HANG;.S
<br /> 2. SUBMIT ONLY ONE(l)FORM"A"for a Facility/Site,regardless of the number of tanks Iocated it the site.
<br /> 3. This farm should be completed by either the I'.[s;EA'ITI'APP CA T or the LOCAL AGENCY UNDERGROUND TA.NX LNSP;'c 1.'.
<br /> 4. Please type or print clearly all requestcci information. _
<br /> 5. Use a hard point writing instr urrr ae Yon arc making 3 copie&
<br /> 6. 'Tarek owner t ost subrm a facility pItA plan to the local agency rss Part orf the application showing the location of t4a VSTa with respect to
<br /> building,;and a sda:arxs(Sec,tioa 2711(a)(8) CCR ;
<br /> 7. 'frisk owner must submit documentation showing crompli a;1c,,,,With sate financial responsibility requirements to the local agency ,a_pao of the
<br /> applicaticn for pctrtrievar USTs[Section 2711 CCR).
<br /> TOP OFrFOR-NI."MARK ONLY ONE ITEM"
<br /> -Mark an(X)in the box next to the ttcrn that best des:rites the reason thbeing completed.
<br /> I, FrxACILIT)SI I'Ia ITtiFiCdtCM ITC);ry&:ADDRESS(MUSTRE C()MPLEI'ET))
<br /> 1. Record name,arm addr ss(physics!locatic ar)of the undeigro .rtl tank(s).
<br /> OTE: Address VILEST have a valid Fhysicaz location including city,state,and zipr6;1e.
<br /> POi BOX 1St;L9BERS ARE NOT ACCE71'ABI.f%.
<br /> Include nearest crams street and name of the operator
<br /> 2. Phone number irrust have an area code, if the night number is the same,write"SAMF"in proper location.
<br /> 3: Check the appropriate box,or TYPE Iris C)E BUSINESS€WNE� SI IIT'(at,C43IL�'t�ILATICD LkF4I 3 �,L tom) , i
<br /> 4, Check the appropriate box for TYPE GE TIUS NESS.
<br /> 5. If F aciRI lSi e is located w nhin It,Indian rc s ,ration or other Indian tratst Louis,,check,the box marked"YES".
<br /> 6. Trrdicate the NUMBER of TALARS at this SITE.
<br /> 7: Record the E ,It.II)4 or write"NONE`in th=e space provided.
<br /> Ii, T'RC3I F:It°FY€31A
<br /> 'ER IN JFt'1ATFC)�� ADDRESS(A,111S I'131.C<EJMPL I:TET))
<br /> 9 '.Z$inplctc all iterns in this sc'ctivn ur loss all atenis arra the sarne-as EC.I lt)N i,If the Sarre,write"SrATIEAS SITE"across_thiscs tido, Besure
<br /> 'to chat; PlI OPI,'R`I`Y t W'vI3l1SIIIP T Y'E box;
<br /> III.TANK C)AYNER UNFORMA iI N& ADDRESS(,muS T BE C(?4tRr, T t),
<br /> Compl w all herras in clads section,unjess ..,1 turns are the same As SFCTION 1;if the sarne,write'SAM8 AS SITE-across this section, 'Be suhz
<br /> to the k TA`K()4§ra\c
<br /> IV,BOARD OF T,QU ALI A t ION i?S 1 S!T)RA(,i-f ,1 ACCC)UNT NUM13FER(MUST B E COMPLETLDI.SEE ARTICLE5,C'ITAFTER 61-15,
<br /> I)1VISIC)'4`?t),CALIFORNIA 11F AI ITt AND`a Alza I Y CODE,)
<br /> Ear€c a your Board of i.qualizadon(.3C)E's)LS I storage fee accomra number which is required before your T�rrrait 3lrl>l'ac ati n cta�t.hc.gsaocestea,
<br /> 14�gistlafi n evert ttaa fi,01,1, 11 cnswe r?r,al yoaa aril receive a quarterly-storage fee return in reporting the 50,(X)6(tirriiat t pear gall>n f,eta§,,r fie
<br /> ��rra;nlserofgaat,r,s}"T%t �4I ara:�cr,rr I,:i"l�s: l',.,.?CiE, �:fl Cisd„Irc;rtaasts+exczrpt£tt> haI°irrl;tPtc stuaa�gc Ccc sts ray�t,rr;+� (°s,�?�st.€ €t i%oa .a�rant
<br /> hate an ac:c.ourrt,.etr+,4act'rc�i11,t=:,ROE or a,'cru hav any gaan -Air1egarclirtg rhe-fee or exczrrpnonq p(tas l t u„I!sc4(,at olt 322-9 `:
<br /> to die 1101,"at,the fo`0wn.c s.,i E,s hoar of E'Q;UA.tofu n,Fact Taxes D: iia n,P.£).Bos 942879,Sac.<s crtF.v,CA 9121v>Ok,,01,
<br /> V, FLr,nlwI,Fx Ll u-8 I^t A C:tAI.,cl...f'C) :Sti3il '') (MUST BE C 02's I'I.F.'1`ED FOR IIED OLI.F;
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