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<br /> Sf IS FOR COMPLETING "A"
<br /> GENERAL INSTRUCTIONS:
<br /> 131' ION 25?iVi„25237,AND 25299 OF CHAPTERII13[ i . I1Id CtCC3II 1ICI " Cti
<br /> 63,DIVISION 20,CALIFORNIA HEALTH H AND SAFETY CODE REQUIRE;OWNERS TO APPLY FOR AN UST OPLRAJTNTG PERMIT,
<br /> 1.One FORM"A"shall tx c,orrepl ztcd for all N`:: PEP-MIT CHANGES GES or any FACILITY/SITE INFORINlATION CHA2 GE&
<br /> 2 SUBMIT I taNLY"ONE(1)FORM"A"for a I acilby/She,r=zgcardless of the number of tanks located at the site.
<br /> 3. This form should be completed by citherthe PI:RNMIT AMILTC",AN F or the LOCAL AGENCY LTz` DE',RCs`ROU TANK INSP13.CTOR,
<br /> 4, ptcase type or print clearly all requested information,
<br /> 5. Use a hard paint uniting instrument,you are making 3 eoples.
<br /> 6. Tank owner must submit a facility plat plan to the local agency as part of the application showing the location of tate:USTs with respect to
<br /> buildings and 11,WImarks[Section 2711 (a)(S),C:CRI,
<br /> 7. Tank owner nam ubmifl documentation showing compliance with state financial responsibility requirements to she local agency as part of the
<br /> application for petrolcurn UST9 jSeet on 2711(a)(l t),CCR)l
<br /> TOP OF FORST:"MARK ONLY ONE, "I E'zh.
<br /> vlark aro(X)in the box next,to me he nn th,t i .,t describes the reason the from is being completed,
<br /> I. FACT.JTY/SITE INl°ORMAIION eC ADDIsESS(MUST BE COM Ll T`£?T7)
<br /> I. Record name and address(physical location)of tate underground hank(s).
<br /> aNO` E: Address MUST have a valid physical;e_scaiion including city,state,and rip code:
<br /> - RO,BOX N:UXIBERS ARF NOT ACCEP"FABIA,-
<br /> Include nearest cross sucet wnd satire of the operator.
<br /> 2. Phone number rnust have an area code.. If the night nusnt zr is the same,write"SAM13,"in proper location.
<br /> 3. Check the appropriate box for-TYPE'OF BUSI-NESS OWNERSHIP(ex.UCJECT'E31Zd'k'IION,INDIVIDUAL,etc.).
<br /> 4 Check the appropriateI-xax for TYPE OF 11USINESS,
<br /> 5, If Facility/Site is located within an Indian rwservadcrrt lir outer Indian trust lands,check the box marked"YES'%
<br /> 6. Indicate lite NUMBl:lt ofTANKS at this SITE.
<br /> 7, Record rhe ET,sA,11T 0 o wv ne"NONE"'in the space provided,
<br /> ZI. 3'IZ(3i' ?t"I`Y C�!s:'Xf; �"eFtCtl��liA'I`I �1 d;.,il�Lyit3: �(�L1S"I"EfII C°�T�ii'LT:TTt�)
<br /> CoynpAev,,.,ail items in this sectiout unless all it€nts are the same as SECTION ION 1,if the sang€;,write"SAME AS SITE"across lhei sec dim« Be alae,
<br /> to Check PROPERTY TY t WNE'RSIMI TYPE"bus.
<br /> 111.TANK OWNER INFORMATION ION&ADDRESS(:v USTBE COMPLETED)
<br /> (:'.omplc°.te,all items in tris section,unless all items are the same as SECTION I;if the same,write„Sr AIF AS STI T"across this section, Be sure
<br /> to check TANK;O)S'N, I:S TYOE box.
<br /> TV.BOARD OP EQUAi_`,1:ATIO\UST S`:OR AGIf 3 Er ,ACCOUNT NUMBER(AIt.;S`I'ITT C4C)tII'I.i:"I'I:.[1,1SI.,F ARTICLE 5,CHA§'I ,i 6,75,
<br /> DMSION 20,C<AIJFOI2NIA 11EAL fil AND SAFETY<a DID,-
<br /> Flwc,your Board of Ec,..,,ltrs,.ora€load',I'S Isto>age few aec:r unt tatssth,.,, ,a1 ich is n,q in d beIovu your p,,�;:niz apl,ic:aelion C.;u kti. ,r.,utx5ed.
<br /> Merl_ �A, . s p' Y ge f a re'u l it repo ilal,t.rc S(M fa f nnilj 1 r r 1, !Ion fe c,Tear on this
<br /> r a as at c13 l a uilires v.a t + erl
<br /> zautn,7.r or r reLc n,, in,%ouT a.'`�Is. The, v,ill ccc"tea p;rsorrswxcty.pas(coat, rti=s=g tiro stvar,riyc,€cc w, -ow, ;a1, h,.v €, 1E rxr not
<br /> hays,ar,ac olwl,t, nba',_ J,h uh, st1�a ur t� vertu a,ay cuest€oras ret ar i.ng utt of aaxa.s€rs,.,a.t';s,a,3 n, -c:c,a,_h,a B01:1<at et:h-a)I 96(i1 or runic
<br /> to 0w_i01",at tt_ lvas,3v_.,u a Iu;.._,acs ad of',FqUali.4aion,Fa el Taxes Division,11,0.Box Er 112%7cT,S� r �tc.xe�,CA 942"")000€1.
<br /> V. €.:�t`sC 1.h .s, .-5. x1. a� .,.s_�:aa..3. 3: .:,,a,��JT >NW'., is <E.C. I.I -CiRI}iTtbtiL,I; -1'I a`;,, r. ..,,,
<br /> a ;A bk 0w ow,r;:r aa�,d;oc cpe nooT,in rnx,eiing theI c d:,tal and Stla,t.fin.,.rc„M:nc pc nsr.: tc ,r�.{. ort;.UST.ars- .c.�r
<br /> acv x 0,,.az at n y as vc_,l a non I.S L`s a t c xcr°ept from this nxfit4u atstt
<br /> VI.LEGAI„S(i i 11`(,,A I IC)N AND BILI_xNG ADDRESS
<br /> Cac.vA ONT,13r,A for c.t_ .i...V, H,,__ c3 for BOTH LEGAL ANIS BILLING.NOf IF,C.A't IONS,
<br /> TANK 0A'NE,1 ORAU I a(C)RIAI:I)REPRF MI ST SIGN`t'�4I7I3r�'II;`I'1tl;i'ORMII AS INDICATED, !Fl. e.C.,1?( E4l'`'l l
<br /> (a)(13)d F T T I.€l"'23 CHAPTER ER 16,C AUTI'CIRNIA CODE,0! RI"s(:rUL TIONS.i
<br /> S`1T1L;CsIC.) IaC.1i It`sI.t1CALAC,I_'sC s
<br /> The c univ has,}€arc,f,ct.,a t r.�.mJ 11th are p, vlc�tc nirat.;l arcs cast be obtaancl"by calling the State Hoard(916)227-4303. t1,c i.;a it€; Twurfa r z; as�be
<br /> assignail by,lae,local of acs',Etc v ever,this r enter must be nualencal and cannot contain any alphabetical characters, If the locid agency plef',-r;
<br /> the State I3u> td to assign the Iacr°.y number,please leave it blank,
<br /> 11'is THE IZI:`PONSt,l'i"I I`s' 01" `FlIF LOCAL AGENCY THAI-INSPE'CJS TTI:FACILITY"I0 Vl-' TA&Yt� HE AC".f`C`It;`CY OF"fill:
<br /> INFORMATION, THIS APPLICATION CANNOT B PROCESSED IF TATs BOB ACCOUNT?NUNIBER I4 NOT FILLED SLC, 'I"HE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" IINFCIRNIA`ITON 13OX AND FOR
<br /> IaClRWARDENCI ON 100.,14"A"AND ASSOCIA"I`LL?FOR,s4"T3"(s)TO THE FOLIIC31 E'G ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RETAINT11h ORIGINALS AND FORWARD ARD T HE YELLOW COPIES TO THE FOLLOWING ADDRESS.TILE PINK COPY SHOULD BE
<br /> .dl:..al\=.i)13Y"ITII: aANl,.f)4rSI ER.
<br /> STATE OF CALIFORNIA
<br /> STAT`E WATER RESOURCES CONTROL BOARD
<br /> 37AT A PROC E,SS11,G CENTER
<br /> P,O,"BOX.527
<br /> PARAMOUNT,CA 90723
<br /> ,31,P3 FORD12ORI
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