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INSTRt&-IONS FOR COMPLEMNG ORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2721 OF TITLE,23,CHAPTER 16,CALIFOR.IA CONE OF REGUI A"lIONS AND SECTIONS IONS 25256,25287,AND 25289 OF CHAI'"ILR.
<br /> 6,7,DIVISION 20,(ALIT ORI+EA 11EAl- II AND SAFETY CODE IZEQ IRR OWNERS TO APPLY FOR AN UST OPFI ATLNG PERMIT.
<br /> 1. One 1 ORM"A"shall be completed for all NEW PERNUT CHANCES or any ACIL fl'A'1S1'I E INFC)I2,'I A'I ION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FOId.'d1"A°"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This fours should be completed by cTthtr the PERNMiI'T`APKICA .1'or the LOCAL AGENCY UNDE'CE1TLC3UND"1"ANK IN'TSFEC OR"
<br /> 4. Please type or print clearly all requ st f infr-rnation.
<br /> 5. Use a hard point writing histru ne m,you are marking 3 copim
<br /> 6. Tank owner must submit a facility pion plain to the local.agency as part of the applicatioi showing the lscaticas f the E15 Ta with real ct to
<br /> buildings an S"sa" 'r~irks(Section 2711 (a)(g),CCRI,
<br /> T Tank owner rnaa .IIuturnit documentation showing compliance with state finmicial reslarinsibility requiranounts to hie local agency as part of the
<br /> application for petroicum LSTs T:Se.ctnwta 2711(a)(I l),C:CRI,
<br /> TOP OF FOR2 "NIARK O:tit::3i ONE frEM"
<br /> 'dark an(X)in the box nest tothe beat that best describes the reasons the farm is being completed,
<br /> L FACILITY/SITE INFORMATION s ADDRESS(A4UST BE CCTt'1fLETED)
<br /> 1 Record name and address(physical.location)of the underground tank(s).
<br /> NOTE3 Address MUST`have a valid physical location including city„state;and zip code.
<br /> P>0,BOA NUMBERS ARE NOT ACCEPTABLE,
<br /> Iraclracde nearest Co€ 1,street and nante of the operator.
<br /> 2. Phone numb=er must have an area code. U sate night nurntter is the same,write"SAME"in prrip:,r Iocati x.
<br /> 3, Check the appropriate,hay forTYPI1 OF BUSINESS C)4§NERS1111'(ex.CORPORATION,aad IVILC.AL,etc),
<br /> 4. Check the appropriate kbt for TYPE OF BUSINESS,
<br /> 5. If Facility/Site is located svithin an Indian reservation or other Indian trust lands,€ aeck the Viox Marked"YES'',
<br /> 6. Indicate die NUMBER of TANKS at this�SITE,
<br /> T Record the ET.,A.11)it or write"NONE—in dzc space,providcd.
<br /> 11. PROPERTY C'WNE'RINFOtd"IrkA BION 1k ADDRESS(MUST BE,COMPLETED)
<br /> Complete all items in tris sc ctioa,unless all items are the same as;S1,.'C`d lON t,If dhe sanzmc,,,`rite"SAyll,"AS SI IT",acrcrs ,has sit+ticm, Ise sure
<br /> tocheck.PROPERT'YO ',%'hITSilIi''IYlllubux.
<br /> ITI.'TANK OAA'lAE' INFORMATION&ADDRESS(M ST BE COMPI..E°ED)
<br /> _,
<br /> Completetill Items inHaas ccttr>n,tz
<br /> enlcss all stesrzs are the same as SF,C;ITC)' !-,,If the same,write „TaA.slla.%s SITL`L°'acr.aas his ace=,ati � f3c vuesn
<br /> to c he ck`I'ANIy t.aW NERS TY E Nax.
<br /> I4' BOARD 4)k`EQAl..r9A`I"I4 N LISI'` Ii)T$t1i E H,'E ''�AC(,'O I NUMBIR{?, �"z 1< C;€""MIPLE IFD S F AR IC,.I.I:SL, II:ia z a_fbc3'7
<br /> DT L zr 10",,20,CALIFORNIACIIl All 1 AND SAI k.TY C Olaf_Il
<br /> Enter Yom tto,i .of E a,tar-I€€ >rt�.Is y,_)Ta a€ storag;c,fec accs a,ant ruinll> r
<br /> RQ,Jstr,..ion ec ith r.n-E(}I.s.zl1 ri."rias°that you slat[rccc:i.vc,a quaatcriy"s° ,au,e, r,-'um t.. a a r �.ut:ra a.,",``<tI r}> t =.;rs se „uc,on dw
<br /> nu;;.a t of afi�.,. a,�:aUcn" .r?�':,c U s'tsI_`;?n E9.T1's u-ilI ode p r osis c'Ne Sit faom, . . ; i�_:,.a.;�. �.. f,,o�, , =s e � � a ,�",�,cs
<br /> have ,_,""SO"t;r if you hav l a,ny(hnest„?rs rcfgar aa,n",a aca.,_W a _xc.z ar« � a,�..,.�cal .t>. ;trl s, ,�+.-f,,. da+• �s>r wtats7�
<br /> o-,taro BOH ar,td.,,Io"L),'',« aLE'..,€;:..s Board of I;cleash"4aativaa,Fuel T'aM-q Division,P,O,I3t>a'`s. .. ;�,�.n�i..,>. ,_ A 94-
<br /> ,9 t.a=)1`e ....
<br /> V. FlE TIOLI'c ;mI'� "z`if •A�'a€.. :fl:�.i S n>.. iiY( .c� E l3I Ct:E 2s1_IA<l, 2'Ca_S l'I Ii f), ,.z .i` ".�I' �.3,. ..< .r.I I:E;° :s��i i .('y}
<br /> -£)iTITLE23,C,If l"I"EK16,CALiFOR I LCLC>IbC,I°l?�.tri?i_A'iit)�4.)
<br /> ldetxtify "l,e rac.t_n xlsl as t by the owner a€ndlor qn3 rator,in nu,. ting the I ccd,;aal and Staa;.1. ..�.,.�� d„r, ,,;�a u.l:�� ",_r;aa.. �t.>wl,r."".',)y
<br /> any Vud,rd or S..a.c,tea,.y as sisal as non-lm: toil;urn t,S'Ts ac cxc3npt from,this rclraat°nm.!-
<br /> VT.LEG AIL No IINC:1'IC?Nti AND BILLING rlDDRE"S
<br /> C hcck{7 a 13t:X for the.s,lcl; ss that will bc uscd for BOH LEGAL AND ITCt.L.i Ci tiO`t la It ,i"':II:I`i .
<br /> TANK OWNER OR AUTHORIZED HORIZED Tvl;PRES]::ti'1A IVE'sit "35T SIC N;AND DA t °Ills,FOR\1 AS a\!:'C A iILD, ,SEE SEC'i a ,-,,<'1;
<br /> (a)(13)OFI'l11"i23CHAPTER 16,,CALIFORNIA CODE 0 ;E,CU ATIONS]
<br /> yySIRL4IION IR n ;T()CAL (,iENCIES
<br /> The eoursty an ya,r€sdioio n to"zrrims+are lneecictenaainacd and can be obtained by callatg the Sta ,Board(' 16)211 4303. n` ,..,1>l r mayr:a
<br /> assigned by the local a?g,cni y,lomever,this number tnrust be nur nerical and cannot Contain any alphalmc tical Clh U a„2czc. if lht. <c>c:al
<br /> the=Mate 23oatc,to assign the:facility tnu nber,please leave it blank.
<br /> IT'IS"1411: RESPONSIBI'Ll".l'Y OF LOCAL AGENCY THAT INSPECTS THEFACILITY TO VEI:IFY THE AC:n i l ,=A(-,Y 0Till",
<br /> LNFORMAT'ION, 'I`S kill AI'Ell.—I,rA"I'10,N C A'.\IN'C3'r ISG I'ROCI1 a"ED IF TI IE BOE ACCOL;N i"NUE,,91)1:fZ,],S OT'I;I E.4gI1 I` , [3:Ea LfY hL
<br /> AGI:iI CY IS RF SP(E NSIf31.F FOR THE CO IPLETIO OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORW AidDI_NQ ONE I:ORNI"A"AND ASSOCIATED FORM"I3"(s)TO THE FOLLOWI°vG ADDRESS. THE LOCAL AGENCY SHOULD
<br /> Rl.TrIJN TlIE ORIGINA[,S AND FORWARD THE YELLOW COFIES T'O-THE FOLLOWLNG ADDRI SS.THE PINK COPY SHOULD BE
<br /> R.Is"F>'t1NED BY TIIlF;TANK OWNER,
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S. `.L.I•,,P.S.
<br /> DATA PROCESSpG CENTER
<br /> P.O.BOX 527
<br /> PARATNIOUNT,CA 90723
<br /> 3'93 FOR012ORI
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