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<br /> INSTRUP-IONS FOR COMPLETING FtM "A"
<br /> G E.NERAL INSTRUCTION S:
<br /> SECTIO 2 11 C)F T 1 LI 2:3,CH APTEIII 16,CALIFORNIA CODE Of,RI 6121-A'IONS AND SECTIONS 2, 2 8C1,25287AND 2: 289 OF CHAPTER
<br /> F 7,DIVISION 20,CALIIaC3R-NIA HEAD-111 AN D SAFF E"Y CODE,,REQUIRE OWNERS O?PPL Y i OR .'_ r.iS >7,".:,. x 1 U,ty z'i Es ".>"",
<br /> I. (}rasFORM`A'"shall bn completed for all NEW pk:}C"ls,11"CTIrNGESr��ry�ACfZLaYIS tI;iJ1Lt)ElkztA`I hCII,AINGI.S<
<br /> 2. SUB-MIT ONLY OXF(1)F()ICM A" or a Facility/Site,regardless(,If the,number of tasaks€ocwcd st.the site.
<br /> 31
<br /> . This form should he co rpiewd ,y cithu tiie P.1- s11`l APPLICANT T or tie LOCAL AGENCY Et.NIJ1IdC;RC,rUND TAN I:'flPE'K"I"OR,
<br /> 4. I'lease tyle or print deafly all re quesi-xi informallon.
<br /> 5. Use a hard point writing instrurncnt,you are;making 3 copies.
<br /> fi. Tank owner must submit a facility plot plan to the uncal agency as pare of the application showing the hwation of the US I's with mspect to
<br /> buildings and landmarks(Section 2731'(a)(1),CC KJ..
<br /> 7. Tank owner merit sub nit documentation showing compliance with state financial respon6bility requirements to€tie local agency as Inert of Ole,
<br /> application for pet.roleurn USTs,]Section 2711 (a)(l l),CCR). A
<br /> TOP OF FORM:"MARK ONLY ONE ITENT'
<br /> Nlark an(}C)in tate box next to the item that best describes the reason the form is being completed.
<br /> I, FAC U IT Y/SITE IN1rORMATION fit,ADDRESS(,MUST BE CCTMPLEITD)
<br /> I. IYecut'd name,and address(physical location)of the undugresund tank(s).
<br /> NOTF',: Address MUST have at valid physical location including city,state,and zip aide.
<br /> P,f3,BOX NUMBERS ARE,,NOT ACw"C:I:iIr'I'ABLE.
<br /> Ltclude nearest cross street and`rtarne of the operator.
<br /> 2.Ph«ne number must have are area axle~, If the;night number is the same,write"SAME"in proper location,
<br /> 3. C".hwck the appropriate V.x)x for TYPE OF T.3USINFISS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc,),
<br /> 4. Check the appropriate box for TYPE C)Tt BUSINES&
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust lands,check the;box inarked TES".
<br /> 6, 'Indicate the NUMBER of TANKS at this SITE,.
<br /> 7. Record the E.P.A.iD#or write "NOMI;"fit the space prclvided.
<br /> II. PROPERTY OWI E'R INFORMATION&A DDR['SS(,N11(ST 11[;COMPIxTTiD)
<br /> Conpletc all items in this section,furless all items are the sante as SECTION l;If the wane,write"SAMEAS SITE"across this suction, I3e sure
<br /> to check PRO111'RTY(JWNERSIIll I'YI113 hex.
<br /> III.TAMC OWNER I\I�ORMATION&-AE)DRI,'SS'(MUSf I31?COMPLETED)
<br /> Complete:all.items in this section,unless all items are the sarin.as SCC"ITON 1;If the.same write" AMEi AS SIT11"across this section, 13c»tire
<br /> to check TANK C)4 N]"0 R'S`T'Y'PE box,
<br /> IV,BOARD 01:I1,.QUA1JZATJ0N t S'I S ORAC,L FEEriC C'.C)L A'I"��Liit43f.�(4'€sS� IIT,C,0Nll'(eT..TED.SI,Ii A a 1 11,,'5,CH Al'; ..I 6,;5,
<br /> DIVISION 20,CALIFORNIA,,tlr A'. III rA\I:)S AvETY CODE,)
<br /> I nw[you'r I3c riot iigt, r izsii isC): f.51 st iia e 1 "Accu int nurnbe r which i4 vc ar ice lxfv,e Your Ix .i ui u ,s i i c iif N p r d
<br /> itegr�traucn to th,fle r3(7_.r,ili era,i t tac t< .wt11 r�ce;i.ve a gc:artcaly Sicrag,c fes,rc,i,.i.0 i;c rc,uorlar3�trig.`.t,i),( t,�..Eu. I., ,,:�,a,i.,.:, lii�<:u,,.�r:
<br /> number of Bail ns pla;rd in your I,s ., '111C ROI'will code I usorzs exernpi froyll u ay:np the., ,,,.z,_C_c,,, 1`vour do av,t
<br /> have „ .a�.c;our itt tici:r t+iilr tl:c i1t i ;of it-cal have,ally,questions tt'g, l'dil.a<the fcc,or css i .,s,u;, >1") ..
<br /> to the I101l at t i;.1 I;oasi�t,ae -c s 13oartl Fu-,IA 1'axr;s U Vki,,Il z'_0.Box. a_�"'4, (�A 9
<br /> V. 11,ST E3;C'OA'IPLE 1€a>FOR III 1 tlt01�1i
<br /> C31t T"1'1'1.1.;�3,<°�1A1'"1`id.It iii,t`.'rhil�Clv'alrA{a,r�h t51'TZiX;E I,A'I I(li'g'S.}
<br /> ally 1 Cdcal?ul Ste c,agi n(w ,is cvidl as rlon ix trot it;i US",S arc aaetnpt froln this
<br /> VI.LEGAL NOill'IC.A ION.AND HILIJNGAl €,11 SS
<br /> C;hcck ONE 13OX rosai UC:. tfi.ut will be ll,cd for 130111 LEIGAI,AND I IJ-) G N(),.. .:.;`t'I..INS,
<br /> TANK O1'NI:R OR, AI UTI 1,11 ?3 K1,11#'�f'sl.'.a"hATIVE M € 4;(\ A_N1)'DA'!I;'a l ..I, .'.li S I C.,.t,?3.
<br /> (a)(I3'C)1''I"l:I.LE'23 CIIAlITTR Ih,C'AI,H OI-C;JA CODE'Cis RF"(4,L'i"1 ON'S.;(
<br /> I:4;S'IRUC'IT€ N 1'OR 1 i 11:I,()CiAl,AG C I1 S
<br /> The county dE t i .;(hC,:ic a rut,nlx a s arc:Irre;&cl €n'lin:,i and can 1 c.obtaincd by c:aliai,nI c,5,.atc .s,aio(916)22'17-4303, '11r
<br /> assigned by tris_ic> A a; ncy;!icsss�.i ,,il;is m nbcr must lie mrncrical and cannot l dv,1�<, I-g,<ncy is,e°1,rs�
<br /> the State dear a to assign the,laci;=oy number,please leave it blank,
<br /> iTISUllai'I,Su'tl sIL1I' O 111F', L€JCAL.AGENCY'IE3A INSI'EC`TS >,1E FACILITY "iOArl_tfIIY '�lli,.AC'"C:LRAC;SCJI tYtl:
<br /> INFORMATION,I`ION, t 1"IS:AlTi,IC A I Itib C.rA:S''eO IM-,, `IZOCESSE'D IFTHE llta IlOF AC.COL N I °M c NIbl:tf .S NOT Fil-LED IN, THE 1,0{_',AI.
<br /> AGENCY IS .fl.;rrtl_NSIOIJ, F01"t.1111 COMPLETION'E.IION' t)1 HE I..C)C.;.AL AG'F'NC,Y IJS1s ONLY' IFI C)a.Yt:A ION BOX AND FOR
<br /> FORWARDING ONE f 01CNI"A"AND ASSOCIATED 1°'O kt"I3"(s)`O 7"111,.,'t�I_i_C),'ING.AI.7DR S 1. HIE:LOCAL r `31,'SN eYF`i;II4)1(.I,D
<br /> REJ Yl ]a'i.O;tical:NALS AND i°"7StW A,U)THE YF.LL0W COP11:S TO THE FOLLOWING NG,AIJDRIf'SS<i'Iil< IIINK COPY SIi<?1;LD I3h,
<br /> I' :T'1"11.D BY a"li i.'i<ANti O14'NER,
<br /> FOROVORi
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