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INSTRUCTIONS FOR COMPLETING "Alt
<br /> GE,'ERAL INSTRUCTIONS:
<br /> SI.0 T IC.)1 t 11 Cl'.A. 3I r,I 2..3,CHAP a ER 16,CALIFORNIA CODE 0 REGULA I'IONS AND SECTIONS 25256,2521s7,AND 25283 OF CHAPTER
<br /> 63,DIVJE 1 N 20,CALIFORNIA HEALTHAND{SAFETY CODE REQUIRE OWaINERS TO APPLY FOR AN UST OPERA-IT C"s PERMIT.
<br /> 1; One FORM"A"shall be completed for all N''T3W PI1RAITT C<'IIr1'vGES or any FAC ILIT'YIST`T E SNIwC?Ivtt+SATION'Ci ANGE,"&
<br /> 2. S'(E NTIT ONLY ONE(1)FOR'NI"A".for a Facilityf i?e,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by citht r the PERMIT APPLICANTor the LOCM,AGENCY C NDE'RC,RC)T ND TANK INSPECTOR.
<br /> Q. Pleasc type or prir$t cleanly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner artiest submit a facility plot plats to the local agency as part of the application showing the location of the IIST s with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank.owner must submit documentation showing compliance with state financial responsibility requirements to the Ideal agency as past of the
<br /> application for 1vttolcurn US"T's[Section 2711 (a)(1 t),CCRI.
<br /> TOP OF 1t<)12'vI."MARK ONLY C)1}:I`C"I IM"
<br /> Mark an(I)in the box next to the item that best describes the reason the form is being completed
<br /> I. FACILITYISrIT INFORMATION&ADDRI?SS{NIV1L7S°IT I31 COMPLETED)
<br /> 1. Record name and address(physical location)of theunderground tank(s).
<br /> NOTE: Address Iyft;ST have a valid physical location including city,state,and An coder
<br /> 110.BOX Lv'C.iN1BERS ARE NOT ,ACCEPTABLF.
<br /> In.Gltidc nearest cross street and name,of the oper<uor.
<br /> 1 Phone number must have art arca cole. If the night st+imber is the same.,write"SAME"in proper location.
<br /> 3. Check the appropriate lvx for TYPE OF BUST E:SS OWNERSHIP(ex,C:C7RPORA'T`IO ,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BI SLyESS.
<br /> 5. If Facility/Site is located withih'an Indian to se ri,afiori or other IndTan trust lands,speck the box marked"YES
<br /> 6. Indicate the itil:'v BER of`FAILS at this SIT'1:3.
<br /> T Record the:E,P"A.11)#or NONE"in ties space provided.
<br /> 1:1. PROPERTY OWNE.R INFORMATION&ADDRESS{11s.;ST BE C'OMI'L LTED)
<br /> Complete all items in this section,unless all iwnts are the same as SEC:'l7ON 1,If the:settle,write"SAME,E,A S SITE"across this srxltiona Ik scare
<br /> to cheek PROPERTY 0WINERSHIP TYPE box.
<br /> 111.TANK OWNER lNIrt)It11ATIO At ADDRf.SS(MUST BE COMPLETED)
<br /> Complete all items ill this section,unless ail items,are.the sante as SECIION 1;If the tame,write"SAME AS SITE`across€.ass section, Be sure
<br /> tocheck'PANKOWNERSTYIII. box.
<br /> IV,BOARD OF EQUALIZA ION UST S"1'ORAGE,FEE AC.0 t)d.N'1°:e1`MBF.I2(4fiL S`Z'l3li C`C)YIi'I,E'fl l7.S .E AR"I`tC.l,l-,' "s,C1I::1I'YflR 6:7
<br /> DIVISION ISIO 20,CALIFORNIA 111`.: LI-11 AND SAIT,I'Y C OI r-e)
<br /> Ti neer voto Board of I�lu,aIizxiun(BOE)t,SI'a.as,agt fee account number which is required lxafore your pa{hilt applic<.aa n&an Inc procv,Siedl
<br /> Rct,akt:ation ,v,flt tnc B01",will cz.se,.d that you.will receive a quarterly storage fee return in reponing thL;OJ0106(test?iT , 6_t i,lflox,sec;;Irae on the
<br /> iiur at> r of. a Ille li(:)E Will code persons exempt from paying the slomgc fee s€z.re![rias v;l€1 not t,e's,aa:. If^ou do nrt
<br /> have an account rturrbcr v.i h the E1f}I or if you have ally questions regarding the fee 0t'oxerrttl>d0nS,plc.asscatl dl,-B(r?,a.c),"rt 322 9069 or ivrste�
<br /> to the BOE at the,foilo% .Uig add,c ss Bos ird of L41u;altxation',Fuel"Faxes Division,11.0.Box 9,12879,Saacaamcnio,CA<}
<br /> lt. PI:'1ltC}T.FUNI US t'FINANCIAL NCIAL R!t SPONSl.(31.1.I"f'Y{MU'S'i'BE C:4:);til'1.1;'1°T:TSSaOR pfs"I'tt()I,l:(,' l t S"i"s ONLY, sill SECTIONS2711 =zs}I }
<br /> OF`1 I L1.?3,CI IA1 TE'R 16,CM-IEC}RNIA CODE,OF RhCzI�LA`11ON s.)
<br /> Identify tltenlellAW(,)Used by the,crwncrand/or op csartor,in mcu,,ztng the Federal and State fsnancird rc,ponsinili y r.c:.larsi ._.,.clt-,, by:
<br /> any I cderal or State agency as well as non pc olcum US`t°s an,exernpt front this suTuircinc,nt
<br /> yJ1.LEGAL NOTIFICATION AND BILhIN'G A a)IRESS
<br /> Check ONE 13OX for the addlcss that wdl be u<ed ftrr I;3O I'll I-FIGAL,AND
<br /> TANTO OWNER MUST SIGN t°N D DATI,,"THE T ORNI ASINDICATED. [il:i`,SF( t 0',;S">r l l
<br /> (a)(13)Of1—T I TLE 23 CHAP'I'T R 16,CAI,ll,ORNl'A CODE OF REGULATIONS]
<br /> INSTRUCTION FOR 1`111:LOCAL AG `tiCiES
<br /> The county an t u kdicticnv attnntx:rs are 1nodc;terrrained and can be obtained by calling the Stato I3o;ard(916)2274303. T he l c 0i y number array 1�
<br /> assigned by tlrt ideal ag.trey,howcvc r,this nunileer inust be nusteaical and cannot contain any talphabelical'charaacters, (f the hx> id:agency prcfers,
<br /> the State I o,m]to assign the facilny number,please leave it blank,
<br /> I1"is 1,1111, PlEsDONS"Es'II.ITY OF THE' LOCAL AGE C;I"I'IAT INSPECTS THE FAC.`ILI Y"IC) VERIFY, HE' i1C:°Ll.`?ACY OF `4116
<br /> IdNFORM A"TIONP T` HS Al PLICA1l0N t-'A.'�N0T Ilk:PRC3CLSS?�c13 IF THE 130E AC:Ct?t;NT NI.,�'1BER IS NOTT IL IN, "lriil?1,C :AL
<br /> AGENCY IS [Cla.Si'4.aNS"BI F FOR THE, CONIPLF-TION OF THE "LOCM.,AGENCY USE ONLY" INFOIC�4A-110N BOX AND FOR
<br /> FORWARDING ONE E 0,,RM"A"AND ASSOCIATT fli FORM"T3"(s)'TO THE FOLLOWING A.I:tT RE'S5. 'I`1 E LOCAL AGENCY fi}1OULI3
<br /> RE AI.\''TIiE ORIGINALS AND FORWARDTHE HE YELLOW COPIES 1T THE FOLLOWLNG ADDRESS.'THE PINK COPY SHOULD BE'
<br /> E E-FAINE'D ill'1 HE,"PANIC OWNER. r
<br /> ST'ATryHy�*OF CALIFORNIA
<br /> &FATE:WATER RESOURCES CONTROL BOARD
<br /> C'IO& .LA.FT'S.
<br /> DATA PROCESSING CENTER
<br /> P.0) BOX 527
<br /> `
<br /> PARAMOUNT,CA 90723
<br /> 3-�0FOROVORI
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