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<br /> INSTRUOONSCOMPLETING
<br /> GENFRAI,INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE,LE,23,CHAPTER 16,CALIFORNIA IA C ODE OF REGULATIONS AND SE{."'1"lONS 252 36,25287,AND 2,5289 OF CHAPTER
<br /> 6.7,DIVISION 20,C"ALII C)RX IA IIF=.AT.TH AND SAFE-I`Y CODE I<I;QCiIRE{OWNERS TO APPLY FOR AN LST OPERATING P'elb nE
<br /> 1,-Ores l'OTlM»A°'shad he completed for all NEW PT:RIMIT CANGES or any FAf.:1LrpY/S1T q'FOR..MA'IIO CHANGES.
<br /> 2. SUBMIT T ONLY ONE(1)FO A I"A"for a Facitity/Sde,regardless of tire number of ranks located at the site.
<br /> 3. This form should be completed by,cit cr the P R t'1IT APPI.]C"ANT or the LOCAL AGLINCY UNDI T:RCsTCC3UND"l'ANK Iiv`II'ECI'OR,
<br /> 4. Please type or Print clearly all,re qu sttd inforinaattcrra.
<br /> 5, Use a hard Point writing anstrza a::°Art ycm are making 3 codes.
<br /> 6. "Tank owner arsrtst submits,facility plot Platy to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings d UW„marks tS t,on 2711 C€:.RJ.
<br /> 7. Tank we ate.ni, sobrnh docurnent.a€.ot sbo ing compliance with Ctate financial responsibility requirentents to the low agency as P'€d of the
<br /> application for ie no! u r US is(a.0 .,,sn tri 1(a)f,l1),CC l.
<br /> TOP OF TrC RMZ 'NARK ONLY ONITE.'T,
<br /> Mark,an(X)hi the box next to the h in that best describes the reason the form is being completed.
<br /> I. FACILITY/SITE INFORMATION A,ADDRESS(MUST BE C OMPLL I7)
<br /> . Record narne and address(physical location)of the underground lank(s).
<br /> IiCYrII. Address NMUST have a valid physical Ic,cation including city,state,and zip code:
<br /> P,O,13OX NUINNIBERS ARE NOT ACC13 JB,E.
<br /> Include nearest cross strc t and mune of the operatcm
<br /> 2. Phoue nunnecr ritust have an arca ccAe, If the aright nuvalvr is the sure,write"SAME"let Ismiser location,
<br /> 3. Check the appropriatc,box for TYPEOF BUSfXI1SS OysW11RS IP(cm.CORPORATION,INDIVIDUAL,etc,),
<br /> 4 Chc ct the appropriate box for TYPE OF TILSIAr SS.
<br /> 5. If 'ac atsty/Site is'I(c.,ttC 1,within ail Indian rc,,ervation or other Indian trust lands,check the box marked 'YES"_
<br /> 6, Indicate the I§U'. BF If kA TANKS,at this SITE`
<br /> 7, Record.etc;E.I',A.IL)it or write`NCN I:;"in the space provided,
<br /> II. PROPFRTY ONYNER INI°t::3t?',arATION&AllsaRESSQIUS]'a31 C`C?MP1J'T1-D
<br /> Cornplutt."11 jF n,e in thi,sc.i.on,unless all iwn-ks atc the sane,as Sl C'!'ON l;If the same.,write,`'SANIE;AS SITE"alr s.r,this R.r cu
<br /> to c}tcck 1'It'C33'ERTY OINNiiRSI1AT'TYPE besx.
<br /> 3IL T ANK(7t'r NLR INFO(t1'1.1 TION L 11)I)IU SS( it S l Iris C�C)11S'I F l'ia))
<br /> Comph"'IC all hems in this section,unless all items are the sante as lSf1'C:1`10N l;If the saatrr ,write"SAME AS S`11"across tris sestiovu Ile
<br /> to check T "SSC OWNI.hS]YI'E box.
<br /> IV.BOA,RI)OF E£ L.ALIM:L 1'I aOV'i 5�1 S Ii7RAGI,FEE'AC,C )l :R l t 4Tt3a r<(MUST TIE C3MPLI,"I T',E).S f„AR t IC'LE r,t;l3AVI t'Pz t 3s7
<br /> DIVISION 20CM 11 Cr NI 1 Ial: 1a l l AND SAFETY C OIA )
<br /> Enle�.Vol,t Board e i Eqo�la,,t era„3OE) ,tat 3rarg c fee accor a nur bet tri'ich rc uir"r fare yourx;=nrt.Ap 1,#ietata >sr WA;-t i ,r=,wc,stsf.
<br /> I.Cl;.,r.a::_:rr ee•srtr tnc 1301.V.IJ ear,A,r('yCa:at? ,r,r Wa11 tz c..avt=€;<,taartc:rty s c,<ak,t r;atarra uz repos?raty,thc sG.O ',(.,x},,11 t r wr ,:a t=,iA,c�,,duc oft hw
<br /> ncrr?,,r OF as ye,r..t S I c, 1'{tc BOEv,ill coder Persons°uxt.a:.frt tcctr 2 Paying�?ri ..<.rsp;c,E.c so v,,it,t,.3i h,_ 1F t'rrt Jc=a,cv�
<br /> have,an Quit}.U_tr,BOE 0a'it Vait have a.ay iiACC in cax..rr aio rs,t>leas;cakl,the iI0k all 916 322 960 of vir;ao
<br /> to the,,Bt3h at tl,, fotis>v,sg addle lss lioa d of ElgU,2 .rats rn,hucl'l'ates Division,J1,0.i3:)x 94 2,8,79,Sacrarncot.,C.:1 942'79 o0A)1.
<br /> V. .'r..t`Ri)r_1_..`, tt'S, FINAN ski lkI.S,ONStlEi ITY(MUST Ise,'CO PLF.'1 `i)I°C7R TL]1LOLF'_,' ,S k' O L',%Sl f,a Cj 10\1S._ }
<br /> Oil'Tfi'T._"2-1,C",l P ER 16,CALIFORNIA COOL OF Rf-.(il;l.,LTIONS,)
<br /> ld,m.f, 11. t ,ihcd,$)a,ci1 bya Ai„ oancr as cVoi oe c t t,in ret tired the Fcdccal acrd S< te,.r •.,.:fa;t _} nisi .a y E�.r.,,.,<r, a,ts.t 1, 3,.yt, , ;t,
<br /> oA S„rr.:ager..s as s-_,l a,t: r,p ,at,t a:r US I's arc went.j-a fair=this KC(Foitaaa t'€t.
<br /> VLLEGAL N'fill-'CATION AND FILLING ADDRESS
<br /> cbc.a ON”BOX forth mina's that will to us-,d for 13C)'ITl LrGALAND BILt ING NOT1111C;:47It NSA
<br /> 1'ASCt)1`\i:it.C):C_gC`1'tittft . l3.flI'ICt.SI..X'TAT't4.1 SI'SICKAND DATE`Slll;FORM StN:)C.Atl1).
<br /> (a)(13)Cs:ITT Lr`23,CHAI''l ER 16,CAL.IF)R IA CODE 0'"REGUI ATIONS,]
<br /> ` S`RUC11ON t'C,zt
<br /> �I H'U LOCA`tL.AGENC.ITIS
<br /> The cotlniy,:aaz,i,ttsdic'• on.."uTnlx rs arc predetenninect acrd can be obta ncd by calling the State Board(916)2 ?4103. lbe,'bicita'I mimhe,fti ty 1,=
<br /> assign.d bye the local aagcuc A;hox,c ever,this number must tae rmniarical wed cannot corn ain any alphabetical"chin acrtera. If the local agvncy
<br /> the State.Board to msigti ahc Baer-,v number,please leave it blank,
<br /> ITIS THE RESi'O SIBILIFY OF THE LOCAL AGE11r Y THAT INSPEC'T'S THE I'/1C',ILEry `l`C.) VE'RIIsS THE, AC".CuliAc,""01' 1111s
<br /> L'aFFC7R IATION, TI I I'S A 1111LICATION CANNOT BE PROCESSED IFTHE Flea BOH ACCC)t,N NUMBER IS s,C)1 I ILLE'1)IN, a HE l )<_ALr
<br /> AGI,' +CY IS RES?'C)°sSIB1.13 FOR THE C0NIPLE ION OF THE "LOCAL AGENCY USE ONLY" INFOR sIATIC) BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED IATED FORM"B"(s)TO THE FOLL€:IUvLNCs ADDRESS. THE'.LOCAL AGF'.NCY S110111L,I
<br /> RE l AIN`1 i tie ORIGINAI S AND FORWARD THE YELLOW COPIES TO THE FOLLOWlNG ADDRESS,'fill,' PINK COPY SHOULD B
<br /> RE i.1IS.t.J BY 111IFTANK OWNER.
<br /> STATE,AIL-OF CALIFORNIA
<br /> STATE,A'I F,W ATLR RESOURCES CONTROL BOARD
<br /> DATA PROCESSING CENTER
<br /> R,O,TIC)X 527
<br /> PARAIIOU 1,Cry 90723
<br /> �.i FtRl
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