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INSTRUCTIONS FOR COMPLETI "All
<br /> GENERAL AL INSTRUCTIONS:
<br /> SECTION 2711 C)1 'I1 i LIQ 23,CHAPTER ER 16,CALIFORNIA CODE OF REGULATIONS SAND SECTIONS 25285,252$7,.ANIS 25289 OF CHAPTER
<br /> 6.7,DIVISiON 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO AMPLY FOR AN LST OPERATING PLIl . .
<br /> 1. One FORM"A"shall be completed for all N f`Ar PERM"=CH ANGE.S or any FACILITY/SITE INFORMA RMA ON CH A'.s GES, "
<br /> 2. SURSTIT C3NLY ON (1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. 'this farm should be completed by either the F'I:RINU`I'APPLICANT as the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrnrtoov,you are,inaking 3 copies,
<br /> 6. Tank owner must submit a facility plot Flan to the o al gency as pail of the application showing the location of the USTs with respectos,
<br /> s
<br /> buildings and landmarks[Section 2711(a)(S),CCR).
<br /> 7.Tank owner inusa,submit documcntats`c n shsoving compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for Petroleum UST-,(Section 2711 (a)(11),Cti.°°:Rz=
<br /> 'FTP OF FORM:"-STARK,ONLY ON L ITE;N1„
<br /> Alark an )in the box next to the item that best describe,,tie reason the forni is being cornpieted,
<br /> I:" FA(.'1LITYISI'I`E IT FORYIA"CI{J DI)R}_SS,'M S"T BLF C C3MPI,F 1`3'D)
<br /> 1. Record narne and address(physical al.location)of the underground tank(s),
<br /> NOTE: Acidness ML ST have a valid physi,cai location including city,state,and zip code.
<br /> P.O.BOX NUMBERS ARE NOT ACCEFFABLE,
<br /> Include nearest cross su et and nar=ae of the operator.
<br /> 2. Phone number must have an area et sr. if the night number is the same,write."SAME"in proper location.
<br /> 3. Check the appropriaee box for TYPi3 OF BUSINESS OWNERSHIP(ex,C ORPORATLON,'INDIViDUAL,etc.),
<br /> 4. Check the appropriate box for TYPE OF 11USTINESS.
<br /> 5. If Ftaciilily;Si?e is located within?air Indian resetvaion or tither Indian trust lands,check the box marked"YES",
<br /> 5. Indicate tlnc N tME3R of"FAKES at this SITE,
<br /> 7. Record the E.P.A.Il)4 or write"NONE"in the space provided.
<br /> IL PROPERTY OWNTR INFORMATION ION&ADDRESS ESS(Alla 3 E3F,COMPLETED)
<br /> T'ED)
<br /> C omplete all hems in dlis secIfi n,unb ss ate items arc rhe same las Si.CTi<) '1;1F the sarna,write"SAME AS S11701 acruss this secticirz, Be sure
<br /> to check T3iiC3I's%R"fY OWNFRSIU?"I'?}ala besx.
<br /> TIL TANK OWNER INFORMATION RMA ZION k ALl IRJ SS CAa ST EF C OMPL.L 1111) 1"'-
<br /> y
<br /> C'carrta,lG,tc all rzc:ns irr has seen.n, r=cs,ad<t s are Lh same as SLC 1TC7 i;if dee sa n ,u"r is SA Ii AS S(TI: across tris secticni, Be stars;
<br /> :ncheck'lANKGWNERS'!`s't'I box,
<br /> I4",T3(:tARD(far is QUAl.'t"1'i ION i.` 1 3TO AGE.FEE ACCOUNT NUMBER(IUS`I"BL C ONIPLF TLD.SLIT ARTICLE'5,{°IIAP11"'R,6,7 5,
<br /> DIVISION 20,CALIFORNIA HEALTH SAF:ETY COI-)E.)
<br /> EW . ou,cl... :.tri�..k..;4teatr.>rt(1'101-f L S 1'stora�c fee tac:count.slumber chictr as required1x fora yrpur Fsyn €ir aislr." t��r can be
<br /> lt.e,t�t.<,ricri vita.rltc IIOI >.i1,ensure that you u.11i ret eivr a quartcrlystomge fee letum in reporting the SC3.€O6(6nr ills)p,�r gallon fee due ora the
<br /> mneme"r of„..l _,;l- d€i;s°c_i.1';'S ole M)F will code,persons exers p t frorn Paying the storage fee so a t rn,w"d n:,A bo sent, tf you do not
<br /> has e eat ac.. "t i.rz.nbc m_,ti the(,�if>o r�i`nota leave any civaestiozzqs regarding Lite fee of x a.ptionrs,tsp as:,Call t(.;cp•I,C}I:at 1>,322-9669 car ria
<br /> to,,tic fJ at€hcc tc_totv...tg adder.,.,Boa"o of Equali,attotr,Fncl'laxes Divsaiod,P.O,I3trx 942879,Seen in rr,o,C A 944 7y,0001,
<br /> V. E'ly'I'IZ{.}I.?; yt t, "t'11 .14C.1.A".. l.l,."C S,,apA1.>i Y(MUSTBE,CONIPLETIED FOR F'iwJ I20I.I:L 1I C s"i's ONLY,311"Li, a,("4 tr} l i t,rtt8
<br /> ld if;thC,,ftp.tl.r_.aO uscd by,,h(,owns r.andj'Or OPCIatcpr,art ri.caltng the Federal and Sat_iinarn,,J zl fe,s"Oo ili, €,.r<"iLi.,%„.", c,' l'.,, o Col b,,
<br /> any a c d; rs-a of Moeller-igc ncy as wcLI a5=,teen-1 .ttv1...4.n USI s=irs,exempt from this rc.citrircrucrc.
<br /> VI,LEGA1,„vCJ i APICATION AND BILLING ADDRESS
<br /> Check ONE I3OX fo the address thw a ill be used for I3C3TH LEGAL ND BILLING`s YFIFJCATIONS.
<br /> TAITAINK OWNER OR rAL,.1.1I{RiZED EIEPRII'SENTATIVE LICS'i SI(i\rA D D ATF l I1E F'"CJR`s'i AS INDICA"1'I 17. 1s,' i;S FC. 'le, 2 t T
<br /> (a)(13)fila I I ISLE,23 CI P t.,116,CALIFORNIA ORNIA f OI)E OF REGI L,rATIONS,]
<br /> rNS'IRLC ION FOR DIF LOCAL AGENCIES
<br /> The countyanjonisdiction nuinb rs are prc.detennined acid can be obtained by calling the state Board(916)227-4301 T hC he
<br /> assigned by the local agcncy,ho%t ever,this camber inust be numerical and cannot contain any allrh:aboiical charactcrs_ I€`thu local agency p icrs
<br /> the State Board to assign rete facility number,please leave it blank.
<br /> IT IS:THE RESPONSIBILITY OFTHE LOCAL AGENCY TH:A'T°INSPEC`T`S"THE, FACILFrY,To VERIFY IIIFACCURACY OF THE
<br /> I"FO-'3),,1ATI{),Y. .I i HS A11111 ICA"I'lON CANNOT BE PROCESSED IF TITL BOE ACCOUNT;iL,'MBER,IS:NOT FILLED IN. THE LOCAL
<br /> AGENCY IS Ki>4,'C) 4 E3?,f; FOR'i`lla3 COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR '
<br /> FORWARDING ONE t c_)RNI A AND D P1SSOC.IAT1;17 I°{)1CM"B"(s)TO THE FOLLOWING ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RETAI IIIF_OR-I aiNAL=S AND FORWARD THE YELLOW COPIES TO iIIE,FC7LLOWWINI4s ADDRESS,THE PINK COPY SHOULD BE
<br /> RL"TAL'sEDBY 111'.TAisKOWNER.
<br /> STATE OF CALIFORNIA
<br /> STA I F'WATE RLSOURCLS CONTROL BOARD
<br /> C/O S.W.E.F,P.S.`-
<br /> DATA PROCESSING CENTER
<br /> P.O.13OX 527
<br /> PARAMOUNT,,CA 90723
<br /> 3;93
<br /> FOR012ORI
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