|
�'SU"IM zs K)"N"J" I:asE (1) <ORM }1a Fart Ez
<br />q
<br />TANK S"�,�,1._s.tDR;
<br />z
<br />P Cis'' IORMA_sFF RK, "ILY O F"
<br />Mari, an ,,:ll _,d ,.oe. £x,`XF to the i<e,=f' 4?"alt @'gC4@ En" , .. ., s �--. c> r?,.:.d_
<br />t.xSl: ORIMA I i.I , ADDRESS (MU! rt t ,F;
<br />}. ,t .d'aa?1�. tuna, and itCa,9@f".,`a5.(€ hvNic,as ,tocation) of !he, Laar .,1xa2�' ,,; aflFiAti�;i..
<br />,art?TF' FAaLI res ML;,`�2' Matra, a 'vand :t;'t,ac.� c[Wm,g city, ,.. t a /i.3
<br />11,03. 13OIS i3IsMI; ARE N€9"I" ACC ` "I'MILl
<br />Sn,, . \,, nea,Cst CYOSs Street and na c of ,tic
<br />2. Pia€ nc nun-0,ur Kusa have an ,;alae c :; Sc. If rh t ,rant tr, .,ais, ,he ,< , c, ,, r; e
<br />.. .. Chc. ;� ,.. 1 ?C. },,.ica4.. t>f) for k�S`I F (")F MJY,'1 S,1;
<br />to hcl-k ,.w iw c b<e<:Pa e t YPf ()F S:It 4, _ �:S,
<br />Vii: =t' ., .he '01FU- 3lat.1l ref °IANKS at 0F.4 SITE
<br />€,o;rtpte,� a., i,.,_s,.> ,n this sect can_ a;ttlesc all atcrts asp 01�: s<.€,., .r. b,l (,t 1(:)`� z 1tt,. , ,,,,�, w,,;v 'tsA°4I1:
<br />this see,4 rr. Besate fl.) check PROPER] OWNERS �� I zI F bol,
<br />iso TAN (WNER I ORM- aA"I"ION Ar ADDRI sS (S USM OF C.`C)MSrs_111"I.'D
<br />Complete E€ a:Wt s za : €+ section_ ttri ss all ilem's are a.,a „ra, sv ,mc. FFr.cr =.,VV AS ',"IT",
<br />",
<br />bas`s Cc .tion, Be sure ear check-TANK. OWNERSITHITYPE
<br />I V, BOARD OF 3QUALW:4NIJ N 1 5F 3' iV W,?,lr A(-'C 4t Q,,T NtsMBEX (1,11Jr, F RY C,(M1gjgV f° ))
<br />,mer yoart Board
<br />Cal,
<br />%:;c��a}ir.ativs z i47� i,'�t` si'o€ �;e fee c.>�a,�t ,� st,� cs� tr, €; l&F o.bir� d c>cassr°e �., j>ci�t l <3x , �,�s.€;�#:
<br />car be Dacca ced, Re istr°aiion whh the BOU will ensure that tra,-� will mcei e a cfu€r err gas rx.be fec, tst re°hc>mnr , siac
<br />-
<br />a(t.Wil (6 raids', per allon lee £Stae ora the trsmber of ; dlo s placcol in ynw I_ S 5, 'Finc BOF wiil cork; t,c;.rsons C :,: ,9 , V0„
<br />aging Ihe slornqpe fee e) r°aturns wil}-still€ be sc-ri. If vasa do =moll, :..t,c .rex av,,oml €tura,,,cr usart 010, BOF, or H, stmt ;,siva, .
<br />>cs.iraats rrg,,aa *.lr Stirs fee or excattplio'n”, Please 3,ri itc IBO z a= 9.632I9!5I5 or ,o the a,, tbc, f:
<br />Boanl of s°,Firs °oilntc.raal Fees C ni"', 1,S), Bca ` ,,9, (:A . 9127-0001,
<br />ITI-FROU fUtl A El' IS,�I ;I L PMSI#C3NSIBILIM' (M21�5'
<br />S le t f;, he melhod(S';t ,ed by the cue°,t �t,I, ar'ca,..�.<�a s. s.a ,t < cg. �..,.. t7 ,x ..a ,.aa =v r, , .
<br />I'..aa Lifictrii7tzS_ !... ;"x g., opined by ally I a7dcral or Sia°
<br />VI. MGM, NO'11171CIMON AND 1IFI,.I.,F CI I DRE
<br />C h ck ONE E ROX for the address that will be used for BUSH=. S.<Swa,iAl, AND, SSS.S.,;SING N£ f"S1F1(;W110,\1 ,
<br />11I'I'I,If,r N'r 3 ^'1' SIGN AN13 3 XR! 111E' FORM AS DIUVn o,
<br />INS-1.' U,C"I:10N FOR '1111aLOCAL AG C'I x
<br />I`he coat ty and iwis'ei ction strza t ere, are predetermined ark cl _, fie r aJlmcd cmh lt- lbe S,ate Board (916)7e)-2,121, hc;
<br />faacifiky n tilt[ f E` t a i lie asset�ed bv the local sa;;eltL'F l " ' cv ( i�,s n a 7c'l- r a nrf r€l Cannotwilf,"mi i'my�
<br />aaita enc=. If Ike 3ottra avelley prefers the State 33ae t£= a yrfa, tt.Y, . ,�_ _..,=,r r,faFs§r= leave tt i�i<„i
<br />ri, IS'm :isTom mull ll-I 1111, LOCAL AGE.IN a Tta<"s't tN,rFfS.t.., la: i"A'(71111Y TO VERIFY 'SSSSA
<br />ACCURACY Ciig.'171I INIORMNI`ON, `II1IS FtPPLIC° ,t=O.':: 9,,.,, .,9PK K B.F. a ;OC1 . ..:,a: IFTJIF 13CI01,U(, 'tfl:i,r
<br />NUMBER IS NCYU F 1g�,1 ,U) IN. ,I"IIS: LOCAL ; C ENC IS RES a'�'°Ft`FI'AIt r, a O IlsI.; =C' I Is =„f`I £3N I1IIK;.
<br />"IA)CAL Cflfa C USE ONLY' Y' INirC3II[41M'IO 13OX AND FOR FORWARDING ONE FORM rt" AIND
<br />S1` '1 a OF CALIFORNIA
<br />INWI`E' WATER RFNOURCAI:%S I S " C.11. IaC)AILD
<br />£',/ C'I SunI
<br />DTVI` s PROCURSINGC #:
<br />P,OBOX 527
<br />PARAMOIJINW, CA 90723 I
<br />a
<br />
|