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INSTRUCTIONS ASI: FOR COMPLETING "Alt
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<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 C)1'''l t t`LI:'2 3,C.I=.Al"I'l"I'l65'CAL,I,E�C7RNIA CODE OF ii f?d ULAI"IONS AND SECTIONS 25286,25 87,AND 252£3€3 O CkiAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALTI- ANI3 SAVETV CODE RI;Q IREWNIJ, S'1C?APPLY FOR AN I ST OP1 RV1-1-N1G PERMIT.:
<br /> 1, Otte FORNI"A"shall be ccanpletod fr all N S'W Plikt'v IT CHANGES or any FACILIT /SITE tIs FORMATIIONI CTTt'CNGES.
<br /> 2. SUIBINUTONLY ONE(1)IrC?RM"A"for a Facility/Site,regardless of the number of tanks located at the site,
<br /> 3. This forret should be completed by lith:r the PERMIT IT APIUCANT of the LOCAL AGENCY Y LIIS`L9tr;IaC'sEt:OEs.ND TANK INSPE,C:TO
<br /> 4. Please type or print clearly all mque'stod information,
<br /> 5. Usea hard point writing instrument,you are making 3 Copies.
<br /> 6. Tank owner must submit a facility plot plart to the local-agency as part of the application showing the location of the USTS with respect to
<br /> buildings and landmarks[Section 2711(a)(g),C,C'RJ.
<br /> T Tank owner must submit documenta'iion showing compliance with seats;financial responsibility requirements to the local agency as pact of the
<br /> application for petroleum USTs[Section 2711(a)(I1),CC&BJ.
<br /> TOPOFFORM:"MARK ONLY ONE ITENT'
<br /> Mark an(X)in the box nextto the item that best describes the reason the forret is being.cornpleted
<br /> L FACILITY/SITE LNFORM A"E'IC N&c AlyD I,SS('till"ST BE C:(>4fl'T.lw"1`ED)
<br /> 1. Record name and addr'cas(physical location)of the underground lank(,). �
<br /> NOTE: Addross MUST have a valid physical location including city,state,and zip code.
<br /> 11,0,BOX NTU'41BIsl2S_AKE,11;6-1 ACCI3t'TABI,I~
<br /> Include nearest crass st.rect and naive of the operator.
<br /> 1 Phone number must b ave an area axle, If rhe night number is the same,write"SAME"in proper location,
<br /> 1 Check the appropriate;box for TYPO OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc;,).
<br /> 4. Check the appropriate box for TYPE OF BUSLNE'ISS.
<br /> 5. If rac1ty/Si€e is located within an Indian resonatlun or other Indian trust lands,check the boa marked"YES"
<br /> Ci. Indicate the.NUTA ER of TA: KS at this SITE
<br /> 7. Record the ET.A,ID 4 ctr write"NONE"in the spa ace providcd. w
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<br /> IL PRC)t'aI"RTY C)WNE"R IXl OR11A T iON<ti:1ryDRES {11IJ s I'l3 Ts CC7 ti�T'Ll:"IS S�)
<br /> as sc cticm,unless all items are the sante as SI:C'110�l;If the sactrc,write"SAME AS SITES"acro."this sec€ico, Besure
<br /> Complete all items in Ch
<br /> to cSheck IpIbC3S';:i{"T'Y C3y�"itiI lZSlils`S`Y'ti tux,
<br /> s
<br /> TIT.TANK OWNER,INFORMATION IO a4 AL)DR SS(�AIUS I t3Tt,COMPLETED)
<br /> ED)
<br /> S
<br /> Completc all€,cert;in t;hes s ction,Unless all items arc€fie,same as SEC'VIC N It If the saane,write"SAME AS SITE`E:"across this secli(at.'By Burp
<br /> tti'che k't"A`t%°)4Y'Nt:RS 1°Yl i.Ixw,
<br /> tL'.1aC3ABD C31 IsC3C'Al_i Ttt) '.-S 1'S`S'{:)? <?tal IEE AC.C.C)UNT\L:MBE..R(NIUST Ill COMPLETEJ) SEE IC"I E 5,C.II:1lrl'S=.P 635, .>
<br /> DIVISION 2.0,C.ALIIrt:)ILMA 13LAa;111 h'i`t)SAFETY CODE,)
<br /> later}>ur iaaa.ard of I`lu.alaaaarc,l{.3Crh}., a s.csra e tee<aecount nurnber xhit h is required before your permit<a,f licat n c.�,.n be proecs<cd, lj
<br /> Rct,'41l,mon rs r h 1110 BOU,w a? n r c'tts t , >cr Willrcccfvc<quarterlystorage fee return in reporting t`e SOJY06(6wil s S iofc fec;dric on 1,11
<br /> z;u, bcr of gallonh;, ,€l„tn yotrc $1U,.Jbe IBO,14Irl csrt pursoras--exempt:f!orn paying th. suhrat ,fee so r,urrn,V"ll "abut.',€`€. If you do not
<br /> have.an account t art'aic r)..ith the 13t)Ii or it,ytri ha-,c any qucs6ons regarding the"cc or excniptions,ple asL c hl1,lee B01"a" 116 3,22=3660
<br /> to the B013 at the.£stay,.,aa,adds. . Boz.rd of l"'qu;aliz ation,Fuel`Eaves Division'P.0,Box ci#2879,Saclamc nio, ',A 9
<br /> V 1'T:iTft T l':1IL 91 d INANC IAL Iii S11ONS+1'II_IT Y(Ml.,,S-1 ISL COMPLETED FOR SSSITROT'la m 1'STs ONI- ",`Itis.STC l'3ON S 2''I
<br /> OF TI"1l r CH 1'ITR 16 C tL1S O C I A C C)DE O hi CS L A I IONS,)
<br /> Idc Att_y the mcd"W(�)Used tby gid.,,ov'ric.>aaXor op,rw r,in nnccting the,Fedcral and Siwe Iirranci<al r .,;,,a Abilil}- " S,'s by
<br /> arty 1 dccrtd or State ag,,,ncy as well as nota p,uoicum Us'ls are excinpi droln hitt,teat irernew,
<br /> I
<br /> VI,LEGAL NOTIFICATION AND HILLING ADDRESS
<br /> Check ON]i"BOX for the,.3ddfcss that will be€seed for BOTH LEGAL AND B111-LNG NOTIFICATIONS,
<br /> TANK OWNIII�OR AT.i"1"I`9ORIZ:=.13SIGN ANT)Dr's` H'1'llf'FORM AS INDICATED,A ED, I SIA{ .S`,C I`IONS'2711
<br /> (a)(13)t.F"E1 t`LE"23 CI1AP1'ER 16,CAI Ih€)RNUA CODE OF ICl.GULATIONS.J _
<br /> INrS'lRUC 11ON hf3R l:;l,'.Isf7C:AI_AGENCIES
<br /> The county air jurisdiction nuinmrs;are lrredc;ter n rctd and can be obtained by calling the,`,"tate 13o:ard(916)227-1303, 14c lac,,'y nuniber rata;be
<br /> assigns€,by local a :ttty;)io evcr,th,s number must be rwrnedc:al and cannot contain any alphabetical charzacter$. If the k ,al t)tl ncy prcd rs
<br /> the State'b),ltd to aNsign alhe facaiity number,please leave it blank,
<br /> ITIS THE la1;ti1'ON 5111.31 :ITY'OF THE' I,OC Al AGENCY THAT INSPECTS THE IAC"IT-UY` O VERIFY THE ACC.t."RAC.'Y OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT Tali PROC ESSED II`THE BOE ACCmOt1NT N[a4fBER IS NOT F(I,I_IU)IN. '7'777;LOC L
<br /> AGENCY IS RA'Si'C?:*,SIl3I_,Ts FOR Tile C:o.%mT'l.S li6N t3P I'I[r "LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR
<br /> F'ORWARDf NG ONE FORM"A"AND ASSOCIA"T'EL7 FORM"I3"(s)T6 THE FOLLOWING ADDRESS, THE LOCAL AGENCY'SlI(3ULD
<br /> RE 1IN`S'Irl C?atI(lLS;ALS AND FORWARDTHE YELLOW C01111;S TO THE FOLLOWLNG ADDRESS.TH&PINK COPY SHOULD BE �
<br /> RETAI:NE'D kid 'l HE I'Atih'.'C}dfN R,
<br /> STATE OF CALIFORNIA l
<br /> STATE:WATER RESOURCE S CONTROL BOARD
<br /> 0110 S, ,E.ET'S.
<br /> DATA PROCL:SSL�CI CENTER
<br /> 11,0,BOX 527 c,
<br /> PARAMOUNT,CA 91723
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<br /> F0k120R1
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