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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> CENTRAL INSTRUCTIONS-
<br /> SECTION
<br /> NSTRUCTIONS:SEC l IO 2131 C tF° I I#LE 23,CHAPTER ER I Ci,CALIFORNIA CODE OF RI,GULA ICONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALI}ORN IA 11EALFfI ANIS S AI FTY CCI:D'F,REQUIRE OWNERS TO APPLY],'OR AN UST OPERATING PEIZmrr.
<br /> 1. One FORM,"A"shall be conipletcd for all NEW PERNUT Caa y SGES or any FAC LTIVSITE INFORMATION CHANGES.
<br /> 2. St BMI`I"ON LY ONE(1)FORM"A"for a Facility/Sica,regardless of the numberof tanks located at tile site;
<br /> 3. `I`his forrn should Lac completed by chher the 11F.RMI1 AI 1'!-'CANT or the LOCAL AGENCY l':R DERCzRCfU-ND TA NR UNSIsFC`FOR.
<br /> 4. 11tease type or print all rcqrttvd It foonation,
<br /> 5, Use a hard want v"Mmg mstrtnniemyou als,makkng 3t,c o .s.
<br /> 6. Tank owne must subm=t a fac',.y 4,_ot plan to the to al.,y,r c.y as part cat the application showing she location ofthe ITS"T"s with respect to
<br /> lse?ileEngs asnd landmarks!sem or 2711 O(S),C;CRJ,
<br /> 7. Tank owner neAst shy w is g eonl ...r, ,,with state financial responsibility rt quirernen a to the local al erwy as part,of the
<br /> application for Iyeuolcra f,iST,( eiorl 2711(a)(! „C"'
<br /> TOP OF FORM:"NI:°u1n.Ia.ONLY ONE?TEN!"
<br /> Mark an(X)as the trrax.noxa.)the item,that be.t describes urc , i�;rrn the'fonst is living completed
<br /> L FA011 ITYISI`1 F I`eFORNIs TION ADDRESS(M ST BE COMPLETED)
<br /> 1. Record Hanle and acl.' ..:fLnl stUullca aua,)3f the nrricrgr<ttratd tarak(s).
<br /> NOTE: Addr-ss MUST have a vid'd physica,locatio;a including city,states and zip code.
<br /> 41.0.Box tiLN3I31,'ICs Ai' T NOT ACC171"FABLE,
<br /> Include nearest cross s,t,eet and nan-lal nay-.lof hie perraor.
<br /> 2. Phrsne ncrrn ct' naasL ha a an sack c x e. If t-he,right numb r.is the same,won,"SAME"in proper location.
<br /> ' 3. Ch<,e;k tltc>zalgpr€3Tsezt€€istsx fcar I`x'T'=C Cy"s L=,.S#yI.sS t?ti�`o,i.PsFIiF'(aa,C'Cllli'C�IZ.IyTifr�,I�1�1�'ILtt Al'.,etc.}.
<br /> 4. Check the appropriate box for TYPE,OF BUSINESS,
<br /> 5, If Fac l la /Site is loo;.e:d within all Inaba.,rc>orvation or other Indian trust ural%,check the box marked"YES".
<br /> 6. Indicat.ethe scf''!ANKSatthis SITE,
<br /> 7. R c�art the.ET,A,I.LI#or write NONIu in the x,ace Provided,
<br /> 11, PROPERTY OWNER I.a a';RM i_ON&ADDRESS(S U'ST BE C OM1 1.1>i ED) C
<br /> C€rnplctr a)I nerns�in This sc ,,�,rs,urs€.s all;tcn:a are tht Same as SEC'11ON l;If the sarn ,wriLe 'SAME AS SITE"acres this section, Be sure
<br /> to t k P1;C)I'I:N't"s 0,Yv I)RSHH,1,Y11i"box.
<br /> Ili,TANK C)1S`1I.I?1NFOia,>a1,1"(It) £k paDDIda.3S(Ml.'S`l`I31,'MM311.,IL11"D)
<br /> Coulplete all ncqls in this se. r a .I W_ all alums aro+Iae saanig as SLC.: ON, r,l ffie--in ,write"SANTE AS StTE"across this smion, Be sure
<br /> Ic,zhl-k I ANK(il' z. �x,
<br /> Il'.BOARD t): i t"t, 1 l r°.,EO," l_ . d,'t'Cal `st.L i-FE ACCt lUNTNIIItTBER(IMU4'1'13141'13; C.OI.i'I.I I El.).SEF.ARIFICLE."<,C11AFTEAZ 6.75,
<br /> Ft}ou:Ii,..u of .,iz. , .?aM)c?1;�tu,. ;.ee�a u .,rFt rtunliac'cw-ha 1,,. o lu 6'd flfora you �. ..t_rss.li .,,. " .r3s ta=rp.<.sed.
<br /> lw
<br /> €,..',;0m1a0'i .ars, llha,, , I rvcm, t.,a a€cartc0 ,tcarage fee rcturn in ocprn ht g the S01_t-L6 :j rscc ,aqonl ice duc,Asa the
<br /> na.n(._.o, ai.a na 1>l ;;
<br />
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