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INSTRUCTIONS FMPPE' ` : FORM
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<br /> GE-,NN EiRAL INSTRUCTIONS:
<br /> SIC,TION 271' OF*TITLE 21 CI€AFTER 16,CAI IT"CtIINI't(XIDE OF RI;CIL`LATIG\5 AND SECTIONS 2M82UST AND 2559 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEA€.I'l€AND SAMTY CODE RSQU3:RE OWNERS O APPLY FOR AN USI'OPER AT"ING PERIufIT,
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<br /> 1. One It£)R "4"shA Im c wylted.for all NEW PI RNUT C:l'IAl GF—S or any f,AC.ILITY/S';D'E-.LN-FO[LkIA'nON C HANOSS.
<br /> 2, SUB-MI`ON'l- 'ONNE(I RAM"M Ara regardless of the nrmrrlbcr of tanks located at the site.
<br /> 3. "this fornt shea;rtd be ctxn z wd by either the IsC:RN.I A APPLICANT or the I.,{TCAL AGENCY EJB:€3ERGIZC UINI)TANK I:l SPLC70R,
<br /> 4, Please type or pant c€early 3a";rc f+at stul an ur ntatz
<br /> 5, Use a hard p,ma writiatg hownen;you are makim A cop€es,
<br /> 6, Tank owner m€an subm t a sac A,plot plan tc)Ic t ,nal agency as part of the application showing the location of the USTs with respect to
<br /> builditags and leandcnarks[Sc.;€An 2711(Qn,CCR
<br /> 7. Tank owner must sthmit duct#a'€tcritation shm with state financial responsib€Iaty requirements to the Intal agency as part of the
<br /> appAication for petrolcurn USE[Sc<:ticm 2A I€XI Q CC'RI,
<br /> TOP OF FORAC"MAL2K ONLY C3INli ITEM"
<br /> Mark-an(X)in the box next to be herr that East describes Be reason the form, is being completed.
<br /> L FACILITY/SITE,INFORMATION,,ADDRESS(MIST BE C"C?MPI.,IETED)
<br /> I, Record na;rte and address(ohq�:l r.x:,ca,c:f of le unFlerground mnkU).
<br /> N£3 FE; Address WWS. hme a v, d ,l si „a lw;a€.:n in=cluding city,situ,and 7,ip corse,
<br /> PO-BOX aN s c.r::Rig ARE N,, '<`,' CF,'
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<br /> -'rest <La>5t ...::.;7;a: t ,,of i.°' vras eiY'.
<br /> 1 m tt 3 t'Wr',..roe sane,write t..SA�9€I"°an proper t sat.ion_
<br /> 3. C'hs.a be afinoThaur An I¢sr'_< . (ex.C°Cl2€ORA"I3_{IN,L-NDI.VIDUAL,em).
<br /> 4. Ch k a,a ace t pt.ate hex fi,r T Y t',.C.i-
<br /> I II'I a € ti!`im 6 I ated MOW W.<.,indan Racnalm m slur ItWin trust lasals,check the Ix>x marked"YES".
<br /> {i. Tndicate the NI'_-1I3LR of'I'ANKS a€.cls is SIS i.,-
<br /> 7. Rccord th,i:F."a',Ak II)4 m Mritw N rNT A the air cr wvi&d,
<br /> 00TIMC a'_Ams in>;€z,c smuo a,ti,c3.as A#,n"are Be sarne as SECIAM M I,If the samq ssaide SAME AS SITE"across diSs s,,,At ai m, Ike sure
<br /> Lc}x€,pN.....:..,:m:,c;i dos son.;:,,uttt;;ss au stem;,an?me satt;e as S(>t...;t:;'I l;Ifthe sart:e.wr€,`S:1'v9L tk5 caTTE,"a<;rciss this sec;e.€cog. I've sears:
<br /> to chcdkTANK
<br /> I4,BOARDOF_C 3 .. MA .. N U FEE ACCOUNY NLtN1tAR ,:L ;T E C` )MM ^TE11 SEE s.0 a WUT 5.C,1,1"IR.635,
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<br /> to .n..._E„, ..,a. a3_ A. ,.,so._�.2 _ __.. a I)"'3l 3..a) .,..... ,�i�s t_ ...a ,
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<br /> TANK
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<br /> ANjos _.1 OR Ak! . );•. ,.4,.<NNATOMN AND.,1,11`iHE F0151 AS . !r..,...-1- j,! ,, . ,_._. ,<
<br /> d—nv," _t.a: y .'.f>i„ xA..ah „u..,.3... V t.,.. .. ..nr:>
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<br /> AGENCY ll.ic 1NATCTS 1 HKg r eC I.,ltY JTE MY al r ( t z'& O II€l;
<br /> P� t t, ,. , _ , .,k:°;?€ l.t.:'�,` ,t .S� .,)1, lI E BOF ACCOUNT r)t,N N'.N_[ER a,zNOT t IL.€<ED M& rsll,x,€WAT-
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<br /> Ac=<, c.; ., N KIN3 , .. , ; POR THE r., >.lfaa.i.3,=_rNC€ :'„... 1ctCtl1'.AGENCY USE ( NI..Y INN.)}l.'Mt,.Eii4BOX AM) 1•'{)R
<br /> FCa,zb` API UNKON h tr ,:M AND ASO)`.Ias ,..1.,l°€;itnt r'M ,O°Illi. t,)'..lDWL\<rADDRI;'-SS,
<br /> R;,i A i S AND FORWARD 11M YELLOW CC)1%S 10 UMFOLLOWING AIJDRLS& I€E; PINK.COPY SHOULD BE
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