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INSTRU TIONS FOR COMPLETING
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<br /> SECI]ON 2711 OF'I'I'I I 23,Cl IAP"a ER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND,25289 OF CHAPTER.
<br /> 6.7,DIVISION 20,CALIFORNIA IIEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING-PERMIT.
<br /> L One FORM"A"shall be completed for all NEW PERF It CHANGES or arty FACILTI ISITE lltirORMA'TION CHANGES,
<br /> 2 SUBMIT ONLY ONE(1)FORM"A"for Faacility/Site,ieg ardless of the number of tanks located at the site.
<br /> 3. This form should be contlaletutl by either the t'LRMi rr APPLICA Wor the LOCAL AOENCY UNDIPRbROUNID TANK INSPLC'ITC)E,
<br /> 4. Please type or print clearly all requested Information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies:
<br /> 6. Tank owner must saatsmit a f'acil'ity pleat plan to the local agency as part of the application showing the Ideation of the USTs with respect to
<br /> buildings and"landmarks,(Section 2711(a)(13),C"CTBI.
<br /> 7: Tans owner most submit documentation showing compliance with state financial responsibility requirements to the local agency as Isa0pf the
<br /> application for pctroleum UST's(Section 2711(a)(11),CCR]:
<br /> TOP OF FORIvF"MARK ONLY ONE rl'EN4"
<br /> Mark an;(X)in the box next to the Arra that;beat describes,the reason the forin is being completed,
<br /> I. FAC IL,IT°YISITT;INFORMATION&ADDR °.SS(MUST"BE COMPLETED)
<br /> L Record name and ad dress(physical location)of the underground raids(s).
<br /> NC TET Address MUST have a valid physical Jia ation including city,state,andzip code
<br /> P,O,BOX NUMBERS AR1HNOTACC1-,,I`TABI-E.
<br /> Incltade zrcarest<xrrss street surd natne,of the operator.
<br /> 2. phone number must have axil arca code, if"the right number is nie swame,write in proper location,
<br /> 3. Check the appropriate box forTYPE OFBUSi_"ti13SS OWNERSHIP(ex.CORPORATION,ATI€N,INDIVIDUAL,etc.).
<br /> 4. Check theappropriate box for TYPE OF BUSINESS.
<br /> 5. If Fac dtty/Site is located Within an Indian r6'�ervatzcin of other Indian trust lands,check the boa%marked"YES".
<br /> 6..Indicate the tiL.Ml3ER of I ANKS at this SITE,
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<br /> 7. Record the E3 PA.11)#or write"NONE"in the spaacc provided.
<br /> ll; PROPI.It'1'Y OWNER INFORMATION&AI.)DRESS('b1UST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SEC:'ITON 1;If the same,write"SAME AS SITE"across this sections Be sure
<br /> to check PROPERTY OWNERSHIPTYPE'PE'box.
<br /> T.H.TANK OWNER UNFORMA'FIOale AI?DRI-,SS(MUST BE COMPLETED)
<br /> Complete all z€erns Irl this scci.icrn,uttlesc all items are the same as SEC'I'1ON 1,If the sante,write"SAME AS SI°P(s"across this"ss ctiom ife,sure
<br /> tocheek TAWS(t)WNEA<S TYIIL box,
<br /> IV,lif)at.CL d7I I.CIf A1utl..,41TCl!US"i S l(.yRAG)E FEE ACC:t,UN INTUMB.R( IuST BE COMIIL TI3,'D.SEE AR l fC'LE,5,CH 6,75,
<br /> DIVIS.1O-N 711,CAl,11,'ORNfA llEAl.iII A.NDSAI I:
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