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INSTR ,; TIONS FOR COMPLETING FORM "All
<br /> SECTION 2711 tai°'1 I LE"23,CHAP-111"R 16,CALIFORNIA CODE OF RFGUI.AIST£)NS AND SECTIONS 25286,25287,AND 2.5289 OF CHAPTER
<br /> 63,DIVISION 20,C A1,1I•'C RNIA I1FALTH AND Sr;I°IaTY CODE REQUIRE OWNER TO APPLY FOR AN IST Ol'IaI to-INC PLEA'TIT.
<br /> 1. t)tsc�FORM"A"shall be completed for all NEW PFRN11T CHANGES or any FACILSTY/SITE INFORMATION CHANGES,
<br /> 2. aSUB'lvft ONLY ONE(1)FORM "A"for a Facility/Sita,regardless of the number of taroks located at the site,
<br /> 3, 'I"his form should be conrplete,d by cith:r the PI:f',..MIT r'tTIPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are,making 3 copies.
<br /> & Tank owner must submit a facility plot plats to the local agency as part of the application showing the location of the(JS'I's with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),C"CRI.
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as Tsars of the
<br /> application for petroleum USTs(Section 2711(a)(11),C CRJ.
<br /> TOP OF FORT,A:"MARK ONLY ONF I IT I\4"
<br /> Dark an(k)in the box next to the it.enn that best describes the reason the form is being comilleted,
<br /> 1. FA I?1TY/gil l;INFCiRMA`ItO &ADDIU,:SS QvIUS aE C-0,MPL1:TED)
<br /> 1. Record name and a dress(physical loca0on)of the underground tank(s).
<br /> NC)"Ila Address MUST have a satin physical location including city,state,and lip oder
<br /> 11,0.13OX NUJib111I:RS ARE,,,,6T"AC°C1,,In AI3LF;'.
<br /> Include nearest crass street and name of tine operator.
<br /> 2. Phone ninmber rnu5t have an area cede. if the nightnumber is the same,write"SAME:"in proper location.
<br /> 3. Check the appropriate box(or TYPE,OF BUSINF;SS OWNERSHIP(ex.CORPORATION,,I;" DIVIDUAL etc.).
<br /> 4. Check the appropriate t chx for TYPE OF I11 SINES&
<br /> S. If J acihty/Site is lucated within an Indian rc servation or other Indian trust lands,check the box tmieked"YIiS".
<br /> 6. Indicate the N Ci'vIBER of TANKS at this SITF,_
<br /> 7. Record the_E PT A.ID#or write"NONE"oz's the space provided.
<br /> It. PRtai'ER"I'Y OW,v;FR INl-'OR.�,5A'IION&AI),')I�l:SS(.�,,l ,7SI'l.i COMPl,L'IT:,D)
<br /> ccrmplety all items in this section,t Mess all iteans are the;same as SI C:'IION 1;ti the same,write"SAME AS ST'I'k"'acr>6s this secd<atn. Be stare
<br /> to check PRCTI'I.1RTY t)bv NERSL=I'TYi'-box,
<br /> TIL TANK f)WIs I R IN 'ORMA"ION,C,ADD 11`;S r 1T_5"T'?1Fu COMPLETED)
<br /> Ce n1 lou,ch itcrns'in th s sccfl;on,,male ss„II, rnas are the same as SECTION 1;If the`rant write"
<br /> SAME AS Sa a L"serer,"Chis wctiozn_ Bz sure
<br /> to clt,.k,a. "ANN(:rWs'\t.r1;i'I'YPE box,
<br /> IV,BOARD O1'Iii;UTALMATIONIUSI S i'C_?.iAGI.FEE.'ACCOUNTNI 1MBER(MU'STBE C£`)_'r'1PLE'l ED,`si:la.AliTiCLF t,t°iiA I,'R 6 5,
<br /> DIVISION 20,C AI_Is'0ji_\IA IffA !vI AND S:kI`Z;I`Y cOlSF.)
<br /> iir,t r your Board of I t z h;_,_a.e a,a3:S3 j l>a I"stars gc fee accorant num hs�r v.hi'cb is required bcfore:youl PC .it alai tic ,,,..:a 1,_.,r., cat,,
<br /> R1,,i,a., a ,on h.._h lac B01,s,'l . r. thr.l x:x,Will receive a quarterly stofage.fez:return ut reporting the`1.1.J`,C,( n. I<,,fell dt.t on tnbx
<br /> ttrtrnlrttrof g ala,s.:IrTa,,.lith year..is�S, l;v.,,�1:.�caul e w..e Ix;tscrsls exwrr.}nt Etch n ln�a}iiaf,the a3.irat, t,a s'ss.r.,,,a.r,, tier Ei.,. ._ ._ si y.G .r h.ac+t
<br /> have all ai cr,..a_t%numbcr w ith 0w ll(A or t1 yt a#aa,e ally u"aestioaas re„arclrng the fcc o1`axxcrhti>t;zsri ,pleaso caul B; ?,<1 :?_, 22 )ai{;r,�r vv-
<br /> have
<br /> to t.h„1101 at tlu:'. �!t.cl,a.al,zre,.on;Fuel Taxcs Division,11.0,Box 942K79,Sac.<h.a vat ,('A
<br /> V. Pi fiOI EI,'M z SI'NNANC!Al.TtziSl't)NSIIilLIT'Y(Ml,S'l'til"'C7(,)MPL.t.1ED FOR PI TR01Ai1.;, ;UST` 0 L):,:1,k
<br /> 01"ll 11.1.2 ,(.'I.,lls'il,R 16,C;ALIF(hVx'1A .(S1 atf01 1 EGUILA'l IONS,)
<br /> ..
<br /> leer=lily lha_m .l.<x,ts) ,ed by ti^<}v r'.cs td"or of,.rat xr,€t,rt c..°i g the a�t d Cal and State tratartcial t,,.csr,as�t,a__, W.c,�,,....,;: + �f v i, ,t "
<br /> any t cdc=aT or St.aic.:,g ,nu, :as h cI,as noon Lx trt.lcum USI ,an excnnpl,froom alis mrp3itcescerx.
<br /> VL LEGAL NOTIFICAIVION AND BILLING ADIDRE'SS
<br /> C'hc ck OME 1; 'X=tarrt._ a.c„C s t.at.°i:-T h,,_'<d,,.r A1C;"I'11 LEGAL AND
<br /> I'A Kfly9'`LI (1i1+.tomIisCSt1. .1.Ts11L, �r. TeS1_yTIV?1-S?C:STSiCL A 191s:�'E`h'I`I11:TrC31t t.1Sz I_1aC...S[d . h NS...'I?
<br /> (a).,.I)OF 11 NLP'3(,I1A11I'l:R 16,`:AIJI t'.CN";.y C'01)i 01 jll,,G ATIONS.I
<br /> The.c.ynty anjarrsdicatioa rrtaa txh ,i,are pl-cdcrermiincel and can be obtained by calling the State Boald(916)µ',2T1303, It,c F�,t.,"F r uornbcrnnay N,
<br /> assigned by 111"toctal ap nt y;ho uvcc,this number rrnust be,nurnedcal and cannot contain any alphabetical cbaaracters. Ifth lo(:al..gc noy prefcrs'
<br /> the Staatc.llo arcl to assnl;n the;facility number,please leave it blank.
<br /> IT Is Tlili"Rl:SPONS IB1.1-ITY OF 11113 LOCAL AGENCY THAT INSPECTS THE FACILITY ITY'1"C)'VERIFY'111E ACCURACY OF'1 fil
<br /> I,XFOR-M TION, "1"111,4 APPLICATION CANNOTBE PROCESSED IF THE BORACCOUNT NUNIB ''R IS NOT I"'II(LED II THE,LO(_AI.
<br /> ACzI.NCY IS RI;SP(3:b;sillLE FOR THE COIN'1PLF:TION OF THE "LOCAL AGENCY USE OI LY" INFORNIATION BOX AND FOR
<br /> FORWARDING ONE FORM`A"AND ASSOCIATED FORM 13"(q)TO THE 1°'L1I.:LOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAI\ LItI,()R'IGIXALS AND FORWARDTHE HE YELLOW COPIES 2£1 TFTE FOLLOWING ADDR7.5S.'FHEs PINK COPY SHOULD T3I;
<br /> RETAINED BY'THE TANK OWNER.
<br /> STA'ITi OF CALIFORNIA
<br /> v 4 I'A`11,"WAT2:R RESOURCES CC1NE"2C1L BOARD
<br /> C/O&W. EZP'S.
<br /> DATA PROCESSING CENTER
<br /> P.O,BOX 527
<br /> PARAMOUN'T',CA 90723
<br /> 3'I3 FOR012ORI
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