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l L 1COMPLETING "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF"IIT LP;23,CHAPTER 16,CALIFORNIA C.ODP OF REGULATIONS ANDSECTIONS 25286,252€17,AND 25289 OF CI'IAI°'TL
<br /> 6:7,DIS'ISIf)'S 20,C ALII4)It"S IA HEALTH 1I AND SAIF TY CODE REQUIRE OWNERS TO APPLY FOR A."'USS`C)PFRA I"ING PEWN1I'I',
<br /> 1. One I°C>IZM"A"shall be completed for all NEW P1e1d.5hiT C:lTANGES or any FACILIT YfSIT zI"�FO 1AT IO CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located kt the site. ,
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDE;RC;I2C21,ND TANK INSPFCTTOR
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use ae hard point writing instrument,you are snaking 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as pan of the application showingq ha`location o£the U�STs with respect to
<br /> buildings and landruarks lS¢ctic>n 2711(a)(8)g CCRI. ) `.
<br /> 7. Tank owner must submit docurrent'atioi`shovving'compliance with state financial responsibility sit is to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),CCRI r �.
<br /> TOP OF FORM:"MARK.ONLY ONE ITEM"
<br /> `Mark (3C)in the boxy next to the itern ghat best do sc'tibus the reason the fonts is being completed.
<br /> 1. FACILITY/SITE INFORMATION At ADDRESS(MUST BE COMPLETE,D)
<br /> 1, Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,ttatte,and zip code.
<br /> P.O.BOX NUMBERS ARI.NOT ACC EP'FAl3Lp.
<br /> �hiclude ncamst cross street mid name of the operator.
<br /> 2..41hpne nurnber mast ave an area code. If the night number is the same,write"SAME"in proper location,
<br /> 3. Check the appropriate lassa for TYPE 431I.BUSINESS OWNERSHIP(cud.CORPORATION,IleDIVI UAL,etc,),
<br /> A. Check the appropriate box for.TYPE OF IILSINI S&
<br /> 5. If Facility/Site is located within an Indian,%servtation or other Indian trust lands,check the:box marked"Y ES"
<br /> 6. Indicate the NUMBER of;T ANKS at ihifi, 11'1;. 1 ;
<br /> 7. Record the E.P.A.ID#6r write"NONE"in tfac space provided.
<br /> YI' I'I�C1Ctl ItTY4:TV NEN NT-C RINIA11ON Sa,r'DDRL:SS'(.Nht*8'I'tl3ls CO?\APLE'I'1<1)) t a
<br /> Complete all items in this section,unless all itarns are the same as SF,C"I°IO 1,If the same,write".SAIME AS SITE"across this section. Be sore
<br /> to check PROP.E.RTY°C)A4'NER 11111 TYP E bsix.
<br /> III.TANK t3WNI."R INFORMATION ADDRESS(M S F M.,:COMPLL E-D)
<br /> Complete all iteans in this section,wiles,all iters are tlae same,as SFU1,1t)N l s Sf iht aaiI,i,write"SANiF,AS SI'l t,"'Across thisBe s{are
<br /> to shack TANTO(1WNT'I'lS'i'YPE hos., A! ;
<br /> IA',BOARD OF I C;}C;r'tIJZA1I0.\US STORIAGI.1 C'.I,'AC.(.'10UN'l'NU."ABER{�tL`S`I'131;C t.)<9F'I.I;'I"I..I> ST,F,ARTICLE L 5,CRAMER 6.75,
<br /> DIVISION 2€3,C,A1.11:0KNItA HEAT 1-1I AND S'AT 111
<br /> latw:et your Board of Eq,a..z.".'ion,i(?,,,i.S Stvazil,c auc account nunib r which is required l)Cfo>:e yatarlxirrn:.a�a,,luc�at;arn call be processed,
<br /> Rcgio,iation wi:1a the)3OI,will a r,sun;hat}ou will acceive a geu.anc-rlystorage fee return in reponi g the:S€)AX)Cs f7G r'gallon fee duc on the
<br /> ntimluur of gaiEor,s F lai e;f,rz a�itar I1S I's. d'hc I3Oaw wa 1 co o Ix;rStxts excrnlst from pay,aip tFac st 1ta M f"cez s,>relmns will not be scm. .If yeas do rats
<br /> have an account at nbcr e tttt,th.es B01",o tll voka lulvc any questions regarding the fce o ctcmtsti:n:,plt.a call tl;c 1101,st 916.322 9069 or write
<br /> to the lloi�at the foliO%v t g w%,yes Board of l q alts aiicun,E1:€tel'I arcs Division,11.0.hiox Vt a.879,S acrarncnw,CA 9,112N,0001.
<br /> A1. IIE,ra(.)1.l;t,1iCSdII.XAN('1;A1,1L,.:II'(),\siiiii:(`I`YttiS!>F;'1"131'(:(`?�1I)1.:,1'1:1)1UIiI'i'flt(}1,1iNYIt.513',5C3:L1,),S, :,;)1"(-"IiC)\S'11711 a}(tt)
<br /> C)1r'I`I'1'I.I.2,3,CII AP Mita 116,C_1I;ID l NIrA C ODIF C)Ft RF( I L,ATl();a1:S.)
<br /> f ay.iat'v .tai';ax t1 od(s)v S,d€i t1t,,;«u alcr a...1 is1,t I4Wr,in t sting tart,F edcraI and Suite Ii a].t.,t, rtsa t.iiy t_uiI i,r ,;i' 1,51 4 ove,.ed by
<br /> airy Feel dal of St.a[s ,= � tss Fill s st> p.tra_ c�na 1" `,a a. Cxb:pt fr,�i flni .quIrvn:erat.
<br /> �'LP.IsCxhL`iU"LitrlC'A"E'lt)1.A\A3 aa1 ..aY(:*11.t).tr".:15
<br /> Check ONE 13 >X iot€ke ad,]Kcss IhW s'illl c,o,e d I:.r 13CJ'1ll LEG AL<ANl)i31L.z�,titl�i3711..fic`1.{)\S:
<br /> TANK OWNER OR.A"11':C3 i11,f:t? MUS l`S 6N rA\'1)D A'1`l:i THF.'F`C 101.AS 1NDI(.,1 x 1:D, ,S,,., s if_.':a1 4 2711
<br /> (s)(13)C7It TH I_El'23 CIIrA 11 iiia 16,C A-LU,01;,`4IA CODE,OF RE.£'UL11'illO`S,l ;
<br /> ItNSTRU `l'ION FORTHE"LOCAL A(iF.,NC:IES
<br /> The Cotunny ars Ju isdicticxa numbers are pi-c'Ictenzained and can be obtained by calling thc4 State Board(916)22'7-4303, The La:,lity number may b'
<br /> assigned by the I)c'ii ag,,ncy;ho;v;.vcr,tlrs nwnber must be numerical and cannot cuntain atrty alphabetical characters. Ifthe local agency prefi:.ts
<br /> the State I3uatd to assign the facility numb(a r,please leave it blank_
<br /> IT is"hl li% I71,4,'ONS,BIIATY OFT1111,' LOCAL AGENCY'I'll AT I:IS111,"C.l'S TIIE FACILITY TO V ,"RIFY THE.ACCURACY OF 1TIE,
<br /> L'tiFORM,1"1'I0\. T!iIS,AF i'LICaA'I ION CAN'NOT BL PROCESSI:I:)IF I`llH 3301-ACCOUNT`yNU),Ili1:R IS NOT FIT LED IN. THE L(.3 W,
<br /> AGENCY I5 t21.,`s.1t7;\?IS!3LE FOR Tflli Ct`)4%F'C.ETION OF THE "LOCAL AGENCY USE C}NLY, I;AI°C)RNIATION BOX AND FOP
<br /> FORWARDING .ASSOC A lF:ti s''`CJRM 13"(s)1*0 TII1,FOLLOWING ADDRESS, THE[OCTAL AGyFNCY°SkIC3ULD
<br /> RETAIN THE O'RIC(x`INAII..S.'!t'tSD FORWARDTHE YELLOW W C OPIE:S TO THE;FOLLOWING ADDItI:iSS:.'ITII:IrI:�IC;::C:C.)PY�5FfC1t,'[,I.a:I3f;
<br /> Rt'' .(41,\ED BY 1.111.. AfixNK"�..)kYNER.
<br /> 3:93
<br /> FOP41MR1
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