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<br /> IN S IC's I N F COMPLETING L I�� MI "Aft
<br /> GENERAL INSTRUCTIONS:
<br /> S1:C:T'I0-iN2'7l l Ol"T`i"ll.i, 3,CHAPTER 16,C ALIFORNIA COLT C31a R EGULATTO S AND SECTIONS 25296,25237,ASS}2289 O 'CII AP`rER, .
<br /> 6,7,,DIVISION 20,CAI IFORMA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR A1ti UST OPERrATS:NCI PERMIT.
<br /> 1: One,FORM`'A"shall'IV completed for all N EW PERMIT CHANGES or any I-ACI YlSiTF INFORMA`110N C'.FIaAiNcgE5.
<br /> 2. SUBMIT O;11,Y ONE(l)F'O121�'I'"A"for a Facility/Site,regardless of the nurnber of tanks located at the site.
<br /> 3. This form should be c(nr)plct.ed by either the PERMIT APPI I AAIT or,the LOCAL AGENCY 1.dTvDO2C'rit.0UND TANK INSPECTOR.
<br /> 4, please type or print clearly all requested information.
<br /> S. Use a hard point writing instnament,you are making 3 copies.
<br /> 6. Tank owner must submit.a fatality plot plan to the local agency as part of the application showing the location of the USTs with aspect to
<br /> buildings'sandlaarnimarks[Section 2711 (a)(3),CCRJ
<br /> 7. Taxalt owner must submit documentation showing compliance" with state financial responsibility requirements to the local agency as p artl of the
<br /> application for petroleum USTs(Section 2711 (a)(11),CC RJR
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark tk box rsext to the itenx that best describes the reason the fornx is hcars oo lett
<br /> 1. l'ACwII ITYl it,a i-NFOIt,A,I A"[ICI: &.ADDRFl,SS(,1LTST Br C:(3m1'S.C'1`€D)
<br /> I, Record name and address(physical,location)of the underground tank(s),
<br /> NOTE: Address MUST have a valid physical location including city,;state,slid_zip code.
<br /> 11,0,13OX NI NIBERS ARE,NOT ACCEPTABLE.
<br /> Include tacarest crass street rsatd name of the operator,
<br /> 2. l"Im le xturnber must haave an area code, If'thc night number is the same,write"SAME:"in proper location.
<br /> 3. Check the appropriate box for TYPE C)l,'BUSI"CIsSS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF I.II,SI:AF SS.
<br /> 5, if F`ac.clity;Site is located within an Indian reservation or other Indian trust lands,check the box marked "YES"
<br /> 6. Indicate the;tit;N1I3ER of TANKS at this SITE.
<br /> 7, Record the E.P.A.'1.I)#or write"NONE"in the:space provided.
<br /> It,, PROP1 RI'Y C rrN;I'IZ LV`lF R,MAT..I.ON&IADI)R '.).>.{41L;S`I'131,COMI't,L;TED)-
<br /> Complete,all iterns in t?i,s vcctiim,unless all itcans are the same as SECTION 1,If the sasnc,write"SAME AS SITE"across this secticta. Be sure
<br /> to check PROPERTY C?AA"NIiRS111I'"1`Yi'I,,box.
<br /> TIL TANK OWNER INF(Ile"b1ATIO &ADDRI SS(MUST III:C)MP1.3:'t'I D)
<br /> Complete all items iii this section,unless all hertts are:the same as SI:C'i10:v 1,If the same,write"SAME AS Sx i E"across this section. Be sure
<br /> to check-TANK 0WNE,11 S T'Y11L box.
<br /> IV,BOARD 0I-'l.,QUz'aIJZA 1-I0 ;L;S"l'la"14')tZ:1£,i1FEE,. (1'IUST B Cf).4Ii'LE11-13,41.I.AR i I(1,E 5,CAI 6,75,
<br /> DIVISION 20,CALIFORNIA IA HEAL`l H AND SAFETY CZi",)
<br /> Beater-voter Board of I qu alizalion(BOl:)UST storage fee account numlw which is requited lx1om your tomtit al tai<czalion a art"fic proc ssed.
<br /> lieaT;tet,.arrora is t;n the I301:a ill esa,rtru tlZat you will reeervc atltaaaterly St or,l;c:fee rc.t>e`rra aaa re;gsor2tsag the S;a..;a(a(t,tt,il 1 t' r;,;ai1"ats fee due,on the
<br /> naa.nt c,r of gaalcrt.s p4aced it,.eo.ar US fss the 130E will Coe<t persons exerr;pt frnatx Paying the storage(,c sea r:tura.:ak Ht not be icia, If>ore do ma t
<br /> haave,an account nuntln"r v,it'h tire;BOE'l or if you have any questions regarding Lee Pec or excralai on> ,pl aase call the B01'all 9:6 322 0669 c x riw
<br /> to the 1301:at Lxe{iAlaau."ag addmss Board Of Equalization,Doer Taxes Division,11,0t3c>t,942679,S acjaoicst� of C"A i
<br /> V, I'EITR01.1:1.;11 IJS I'FI:NAIN IAI,IUsSPONS.IIIII-rry(Sius`ll BE<a)asrlpt.l.'t"im IuII t'tJ'rIwf v1't.;'i c S1`s(:7NI-Y,SFJt.0,-FONS 2711 (a)('S)
<br /> .Cli Tl'TLE. >,C11AP I'ER 16,C Al_.11'ORNI A C:O1?t`OF ktXA' 11GATIONS,)
<br /> Ic:crttly t¢tc tncahcxl(.)ta,,ccl bythu owner and/or o(ta;ratar,in n;c,ctutg the Federal and St<aw lraatatca:tl ac°sis"aats'iht(ttyA USTs c>,_ti"a ,.l by
<br /> any F dural or State agaicy as well as nosy p tzoIca zn l"S'Fsyare,cxerupr Irrnxt this rcquirement.
<br /> VI.1.l:Gra L NOTIFICATION AND Bll,LING ADDRESS
<br /> Check ONE i(,I l.;t thc a,'.cltess that will be used for BOTH LEGAL AND BIL,l,ING N0I tl R,,A'1,r;`S,
<br /> TANK OWNER OR AUTIJORIZEID SIGN rANI:a13A"1`lz"t'lla",laC?1ZM A,l'DIC,AI 1.11 I.IT S ?('110 N S,'.' 1
<br /> (a)(13)OFTTLE. 23 C.HAVI I,R 16,CALIFORNIA Ctl'DH OF IdEOU1,xATI'N&I
<br /> LSIIii1i0O lEz1 ilC1C:r1LAt)tC11?S ';
<br /> The cc only an jurisdiction ncaratx rs are pred6tennine d and can be obtained by calling the;Stare;3o:at l O 1Ca 227-4303, t t,c l ;.iia;y r�,ars>tserttaay I a
<br /> assigned by feta lo,:al tagolcy;however,,this member must ba,nurnedcal said cannot contain any alphabetical characters. If the local"agency pr€kiur4
<br /> the.State Beata to tassiga,die facility number,please leave it blarrak.
<br /> IT Is 'l"t11: 1t1:tiI't.)ti§?(3li.t"l Y OF THE IMC}CiAL AGENCY THAT INSPECTS S THE FACILl"I"Y'10 Vl,Rfl,' 'THE' AC°C:,'R A<.Y OF `l'HE.'`
<br /> INFORMATION, THIS A1111 ICAT ION CANNOT BF PRC CESSED IF THE NOT l{ILLF'..D IN. `[TIT.LOCAL
<br /> AGENCY IS RHIS1' )NSIl3I.E FOR THE COZ%1i31.ETlON OF THE `I,OC"At< A<:.ilz\{,Y L;SE ONLY` I";FORNIA' ION BOX AND FOR
<br /> FOR41'AI DiV.p ONE FORM"A",AND ASSOCIATED FORM"13`(s)TO THE}a'O!I.f3W '3_ G ADDRESS, THE LOCAL ACzt:."YCY SHOULD
<br /> Till-F,-.1 1IIF.OR!GuIN ALS AND FORWARDTHE YELLOW COPIES TO 111E FOLLOWLIINGADDRESS.TIIE PINK COPY SHOUL.T],BE
<br /> RE AISI:D B I III[,"TANK OWNER. ..
<br /> STATE OF CALIFORNIA
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<br /> sTATE�rATER RESOURCES CONTROL BOARD
<br /> C/o'S'.V1.I:.ET. ."
<br /> DATA PRCICESSLNO CENTER
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<br /> RO.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3 5 p 12ORI..M
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