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<br /> INSTRUCTIONS FOR COMPLETING FORM "Aft
<br /> GENERAL INSTRUCTIONS:
<br /> SI:C;"I ION 2"711 L:)3' i 1"I z.Z;2:3,C HAP"IER 1 G,.CALIFC7IsNIA CODE OF REGLrI.A"ITC N'S AND S}CT.IONS 25286,25 S'7,AND 25289 OF CHAPTER
<br /> Ca,7,DIS ISION 20,CAI,lf-'O .\IA III»AUI'I AND SAFI" TY CODE REQUIRE OWNERSTOAPPLY FOR AN LSI OPI.,,tZt1T--,T'.PL, .\4r .
<br /> f..bne I°t3RNI"A„shall tic complctcd For all N i:W'I PERMITCHANGES or atiy FACfLI fSITF S T="OR.NIA,no°r ctih'IGES.
<br /> 2. :rSt:ll3iNIFF ONLY ONE(1)FORM"A"for a Faci:litylSile,regardless of the slumber of tanks located at the site.
<br /> 3. This form should be completed by either the PERMrr AP1111C ANT or the LOCAL AGENCY tTlul7iiteCaIe'OL;ND I'tiNK INSPECTOR.
<br /> 4. Please type:car print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6, Tank owner must submit a facility plot plant to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings and lttniirrnarks[Section 2711 (a)(8),C:CRI]
<br /> 7. Tank:owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application forivtrcilcurn USTs[Section 2711(a)(11),C;C"&Ct
<br /> T011OFtFORM4 "MARK ONLY('NliITEM"
<br /> ;dark an(X)in the,box next to the item than best describes the reason the form is being completed:
<br /> I. FAClt1T"YlST1'1:!Nl,'Ol�MAT'ION&ADDRIr,SS(:41LST BE COMPLETED)
<br /> 1, Record name and addles(plays€cu location)of the underground tank(s).
<br /> NOTE: Address NIUST have a valid Physical location including city,state,and zip code.
<br /> P.0BOX NUM14I3FRRARENOTACC,'EP1"ABLE-
<br /> Include ticarcest cross street and name,of taw o)craator.
<br /> 2, Phone number must baave an area code. If the,night numbor is the sarne,write"SAME"in prop€;rlucattiona_ '
<br /> 3. Check the appropriate K)x for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Checkthe;appropriate tx>x for TYPE OF BUSLSESS.
<br /> 5. If 1 acUisy,`Site is located within an Indian;rtsersr ation or other Indian trust lands,check the Eaux marked"YT.,.S"
<br /> 6. Indicate the NUMBER of'TANKS at this SITE.
<br /> 7. Record the L,RA,11y#or write"NONE"in the.space provided.
<br /> 11, PI f;3P1:13T'Y C>V Ii CCI rl'C)I,FTA"Tiff' Ai}1)t Ia4w>(L11 s'hLII C£'y Pl E'tT[�)
<br /> C"ornpletc call items in this sectiou,unless all items are the same as S1,C.'IION 1,If the sarne,write"SAME,AS SITE"across this section, lir sure
<br /> to check PROPERTY C>WrNE.RSHIP T flak box.
<br /> III.TANK OWNER lNIaORMA s ION& AI>DRFSS(MUST Ill.',COMPI,I T ED)
<br /> €"omplew sal.aeras m Hats sect.o�n,unless all nems are the same as SEC11t N 1,it lis sante,w,at<± SA a3 AS S..L„<oct,s aa>a c:. Pc,Marc.
<br /> to ch t k`i`ANK Olay lv I,'R`s"I 5!'L Exax.
<br /> IV,.?£)AlZI')C?la`i?,< :l 1MzZ t`1'l`£) 5, s"i`C7(?,�(rl,i lil: 1C C C.)ti4`I" C F313It(MUSTBE CC)M`#tLE'l PD,SEE:ilv"hit"1 F 5,Cl I APTEP 6.15„
<br /> DIVISION 20,C'AI.II OR IA 11FAL-III AND SAI E s Y Co ,)]-,)
<br /> Bruer vo'un l3,rard of EquAix tion(sC)I?:j UST salla,, tee account number v3hicia is reyuin"cl bcfore,your p",nnit tt,asica6o)....: b,",.,r�.c••�^d
<br /> ,ac;11t E w', a .t yon will,;:c 6ivc a,ltaarlerly s w gc fcc rcta,rn in reaprartcrnt;t e.,S\ ,C.tc';eaL h ,ares dE .a
<br /> :u°aafa.r o'f,a,I r.'1>,«._.?Ent yom l ,S t, ;t,c,S(xu will codQ p;rcotns ex�rm z fi..n P" m,the ��r_ v�.ct r_,r_,:. , .l.. ,. _
<br /> h lle,u,a t.,,n?7 r t,rn 0b_,ROE or a,°ou have any questions regal i =a t,aw ca:crit_wpiion.,,
<br /> to th .l_)i�,,t 0—lo.10 .aa;,a,ld-,,s Not ,-,d of 1,qu a3SL.alwnt ,ue!T;a�,cs Divi,i.:nE,P.O.13ox'f:227',, r1
<br /> V, I'I?.`i'RO .(..U,e,L'S I NNANCIAL 1IFS?'ONSIMI-IT°r (NIUS"I"BE CO?vlllLr.11"D FOF.1'IoI ROILL.'�:M l S`1"s ONL",„SIJ� "ONS ;,
<br /> ,,,,d try t! ovs_cr z ”'>,o> opc favor,in z.eve ::,g,the 1 c' raI a ld Stu o t,.,zncia ,ac'
<br /> any, .1c:-.s, ,,,:r ,,gcn-;Y as,,_ll a roll pcire>Ica„n h"S"I's ar., xc. :pr.frencrn this, :auircaa cat.
<br /> VI.LEGAL No 11 I'AION A\i:)WILLING oG ADDRESS
<br /> talus oviJ b, ol?,ed J.r 1301`1 Ll"GAL AND MILLING\(r I tl ICA„?l 5_ 'I.
<br /> TA`:K OtArN11"R ON,A U111 ORITIZI'.D RF1'<,I.SEN'l Ai 1'IVE MII'SsT SI(N AND DATEITIII;
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