|
7
<br /> 0
<br /> INSTRUCTIONS FOR COMPLETING FORM "it"
<br /> SEC:I'ION 2'711 OFTFITLE,23,CHAPTER=A'`i ER 16,CAT IFORNIA CODE OF REGULATIONS AND SEC ONS 252 12nQ AND 252139 OFF CHAPTER
<br /> 67,,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWSM S TO APPLY FOR AN US'T'O1'TaRA-II; GI EKIMIT.
<br /> 1. One FORM"A"shall be completed for all N iEW"PEIR IT CHANGES or any IFAC:L ITYISITE'.UNFORMA'C"SON CHANGES.
<br /> -1 qUBIVIFF ONLY ONE(1)FORM"A"for a FacditylSite,,regardless of the number of tanks located at the site.
<br /> 3. This form should be aomocted by either the PER.Tv1TT AI'TFIKANT car the LOCAL..AGENCY UNDERGROUND TANK I'NSIIEC`T OR.
<br /> 4, please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3`copies.
<br /> f. Tank owner must submit a facility Lilco plan to the local agency as part of Me application showing the location of'Me USTs with respect to
<br /> buildings and landmarks[Smdon 2711(a)(1,CCRI.
<br /> 7. Tank owner must submit documentation showing"cott,pl€ance with state financial responsibility regatircrne is to the load agency as Friar of the
<br /> application for petrolcum UST's[Section 2711(a)(l l)a CCRJ.
<br /> . .TOP t)4°FORM:"MARK ONLY ONE FTI Nt
<br /> 'Mark ar(IC)in the box next to the"stent thaat,!test describes the'reason the fomt is being completed,
<br /> I. FACI:LIT'Y/STrF,LNIORMAIION&ADDRESS(MUST BE CO'x PLrTE`D)
<br /> 1. Record name and ad hms,(physical location)o4 the underground tank(s),
<br /> NOTE:Address NIUST have a-vatid physical location including city,state,and yip code, � e9
<br /> P.O.BOX NUMBERS ARE NO`T'ACCE VIAI LE,
<br /> Include ncamu cans sucet and name of Me c°sc rator.
<br /> 'i
<br /> I phone camber niust have an area code, If thc night number is€ie sacra.,write"SAME"in proper liacafifan,
<br /> 3. CSaeck Me aplsrcpriate hu for TYPE OF BUSNI SS f}WNERSH111(ex.S`,ORPORATION,INDIVIDUAL.,etc.),
<br /> 4, Check the apptopriate box for TYPE OF Iii SINESS.
<br /> 5, If F°ac dityJSite is located within an Indian rc serva ion or ulcr indian trust Burda,check the Asx marked"YES.
<br /> 6. Indicate the ,U,NIBER of'TANKS at this SITE-
<br /> T Record the i.T`.A.Lit;#or wnw `NONE"in th,e space prcavided.
<br /> C:nrnii:cta;all :"a.ms in A._action?ia.,e,ss ad i.wm>arc.be sarrru as SIC,11F3N T;If the s-arae,wrrce-SAME AS I}Ff"ay.o., this M=<ii<xL Be we
<br /> to check i'IiC'sa'i.R Y 0n4 NI:RSI11i' 1 ii l' ox,
<br /> 1i;.TANK OWNER I'r:"C RNI r..iN A tn17T:R `94
<br /> Completc ani imni: ni this< oion,nolcua all iteeits ars_Lie name as;SECTION l;<t'We am,wi.e c."SAI L:AS S1117;Ai s ,a.lilt gmtion. Be mmi
<br /> to ult ,�k TANK C Re'N -',RS'i YPF.,box,
<br /> 'IV,t3C7ARD{ll ,,,QU'tII A'l ON C%S`4 STORAGE FEE A€,t.°C)T.Ii"ti'I`NUMBER(NIUS, II£ €:°t) tP:.TI 3.T3.SEE A T ,:".1.,,5,CH 131,1£
<br /> t>1V SMN It CA11l°C)RM ,HEALTH AND SAFETY CODE-)
<br /> Emu y,,.is Bond of tai a<.wk c 010do U`s[ sum c Lee a=Amt number which is mVirud Nfore y= qv ie TaKOY am 0 l,m,cT-ol
<br /> Ice!, „ikin"A On BOP YA=w...QM s. ."A!m c c a c,amterly r ra,e f �return bi„rcpo ti ii t.r SJ.?.v [,'e J .
<br /> m,. kr of gaMm pincad,rA ,� ars. tt_.�1C i;u.,lccccTsrscr.; emmy r°, i„e norac i, �t .r.. .. m4 by li 3,,..
<br /> 7rs;�a i.«,.c3,_,t nuin�tit.r v i.h iiey 1i01T or i! yoit have any qple dons re,irlding me we or dye c.i 6_>iis,r?,,,w ON 1AX4 W 9j,<< 12 9609,t . .._.
<br /> to tar,As,01'a,the,i.die',, ,ra Ale”Bond of Equarl atin ,Fuel Tmes T)as>;4+3r?,PD. i`.w 9407,4„_,<w w i A .,9 id, f '.:)Q,
<br /> v. T'l:l llO..T f m un l i INA N(.`IAL Tl t,4T'€ NSI!2il,,I`t`t``l1u s'l RE,C:'()liiaa,I.,1::)Fol? SF ;ONS
<br /> \..
<br /> OF 11 HE 21<:'<..AP TEIR T£i,CALIFORNIA i r,}RNIA E.`ODI;,flu 1r,..t:i.t:1"I IONS,)
<br /> 11;wAy Ay Me. w...d,(.)uwd by le.man a. ? r e.l,mea.A.r,i_t i,is b%the Federal vr..e u*aw z, a dal mytonsilky ,,l, = i l>is r
<br /> any!%&Q cu Size ag , . as.pid!us non petfol""iul 1:5'1's act e xcinp,front t :
<br /> VI,
<br /> g f
<br /> ION
<br /> AND
<br /> LING,ADDRESS
<br /> Clack ONE _BOX r._dw wM;:.... ,r w.y,i?i e umd tAge OT11 LR A1,.LNi”B1'i,..sC',NO!iNCA 1ONir_
<br /> "isA:`a,i.(;
<br /> /
<br /> {�'�;1,3_.'.S.
<br /> ZAUTLIOR.711.,tR'Ei'1ZESENTAi1I"Cr:NEST SHIN AND DATE. :' FORM AS1NIl( .A101 ; ., :,...,,,, , MS tl
<br /> (Qly OF TU11 23 C (t. IIIIER 16,C.;t;TDORNI.F C OF)E OF RFi(- r.A,,1ONS.i
<br /> INSTRUCT ON FOR JIM I.CICAL AGENCIES
<br /> Ile COMLy Mi t.eta..,iiciicri atiia,i(sCt. etre pr.(kava'i,I<m!man can he oNained by c al,ing the State Boa RI(9%)22 A 301 1KAndoynanTninaytei
<br /> assigned by be Ex rl ag, _sy;hoia yr ,this riuniber must Ile nurnr rit aT and cannot b c main wj Ap R w ai c$iwww o H No k K uVmy T rz wry
<br /> We State Lacs_n ser alt i Tie facilky nun bcr,please leave it blank,
<br /> IT ISTHE HE RE`PONS .TIi.I"Y OF THE I.r:WyL AGENCY THAT I"ti`;110 TS THE t A ILIE'Y"1'C? S ERII-N THF ,"A,t.KRAC:".Y OF `I'i1z
<br /> INFORNIA110N. 10S APPLICATION CANNOT BF,PROC I.SStID I F I`II1,:TC)E ACCOUNT NUNA;3T.ar C;;'*O-i FILLED EN, 1 HE,LOC'Al,
<br /> AGENCY IS RESK)NSWLE FOR R "rill^; C.`,C)N1i I T'IAN OF TIM "ITCAL AGENCY LAE ONLr INN t:il y AI C(N BOX AND FOR
<br /> FCIR .zlzi.ENG ONE 1 ORM'°A AND ASSOCIATED TFC.IRM"B"(s) 1`0 THE T'£IT.L lW iN I-i Al.al.R1.`3S. I?I;i LOC"„1i.,,t?CsEN(.''i :SFT£?ULD
<br /> BE,F1.N THF.0II1C_rINAUS ANI)T't:}RWAIdI:t'THE Y 1.l.0W COTIES'TO T111i,FOLLOWING til)tii'ESS.TIIE PINK COPY SHOULD BE
<br /> 3ZETAI"e?°iyL IHE, I'AN„COWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WAZIs.R RESOURCES CONTROL BOARD _
<br /> QO`.a`;sa.F...T;.l'.S.
<br /> DATA PROCESSING CENTER
<br /> 11.0.I3OX 527
<br /> PARAMOUNT,CA 90723.
<br />
|