|
INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS
<br /> SECTION 2'711 OI TITLE 23,CHAPTER 16,CALIFORNIA CODE OF RFiGLtLATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEAL."FFl AND SAT-T-TY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed,for all NEW PERMIT CFI ONGES or any FACILITY/SITE LN-FORMATION CHANGES.
<br /> 2, SUBMIT ONLY ONE(1)FORM"A"for a Facili€yr'Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be ccnnpleted by either the PERMIT A PPI.:ICAN C or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. ])lease type or print clearly all.rc:c?ta€;ateol inforraaatican.
<br /> 5, Use a hard point writing instrrrnent,you art;making 3 copies,
<br /> 6. Tank owner must submit a facility plot plan to the Tical agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR 1,
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application Pott petroleurn US'Ts[Section 2711(a)(11),CCK),
<br /> TOT'OF FORM."MART;ONLY ONE ITE—k1"
<br /> Mark an(X)in the box next to t1;e item that East describes the reason the form is being completed.
<br /> I. FACII.I T"Y7S17 E INFORMATION&ADDRESS(NUST BE CO TPI,E11D)
<br /> 1, Record name and address(physical 10 ation)of the un&rgyto>und tank(s).
<br /> NOTE: Address MUST have a valid physical Iaxmation including city,state,and zip wde.
<br /> P.O.BOX NUM- BIERS RS ARP.N I"t AC'C"E'.P'i'AI3LE,
<br /> Include nearest cross street and name t<f t1;e operator.
<br /> 2. I'1€ane number rrius€.have in area c-sxhv. ".3'~,e.night number is the same,write"SA11 E"in proper location.
<br /> 3. Check eh€ appropriate b.x for"I'YPI3{ Fz 13C:MINI SS C) sF�R,HIP(ex.C'C)RPORA'CI:ON,INDZVIDUAI„eta:}<
<br /> 4. Che(:k the appropriate box for i'Y'13 C}i:f3US �F S,
<br /> 5, If Fa6lityiSi?c is located withiaa r€'a:ra Batt rc'sery ation or zither Indian trust lands,check the:box marked"YES".
<br /> 6. Lxficaw,the NUMBER o£"TANKS at ihi�,SIIEI
<br /> 7. Record the:E.P.A.ID 4 or write"NONE"in the space providcd.
<br /> TI. PROPEA1Y OWNER ER[N1`C>12MA3IO &ADI)Rz,SS(0.'11;i•T Bl,-'C;OMPl.ETED)
<br /> C.orrplete all items trr this section,unless ill at::ms are,the same as SECTION 1;If the same,write"SANTE AS SITE"across this scct.ton. Be sure
<br /> to check PROPERTY OWNERSHIP I'Y'i'i:1x;x.
<br /> FIi.`I'AItiK C)trr`\I':is I'� OR�IA I It)'ti�A �1.)ILl�S C�:IUS"I"f313 C C3thFI,i=`I'F:I3)
<br /> Cod,"Rete all it crus irr Iris sectio.,,unlessail items are the same as SEG FlON 1;L:£the same,write"SAbIE AS ST'I'R::°r;cross dlis se:tiorr. Be,Sure.
<br /> to o:hcck I ANK C WN!N 1 S"TYPIE'box.
<br /> IV.BOAR`?OF EQUALIZATION L-' `s f Fi"r"' tC f{_,,;`v E \L MBF"R(MUIST BE COl\4'I.Ta.:t'ED,.SI;E ARTTCI_l,5,CIIAPI ER L.''S,
<br /> DIV'IS10N^(',CA .ORN -z f i
<br /> � ^� ' ^a'i `illi, tiC())l'I,j
<br /> lattr
<br /> your B ail of: €ti a1, -.,s 13, > a f s ;tccou t n trnb r Vtihich is required bo fore your vf"IWIioll U.')t
<br /> roc:a.it.a€Jedy a c sage fec;return in r .,;r in.;ph S}.{a�r3s, tl;c,
<br /> numb, of alio;s d iaa y;aar I.S.
<br /> ('
<br /> ? „y
<br /> i
<br /> iia the<30„, t l.ie u,,. "Cl C..`i t1
<br /> V. PTs-RO li I S` FINANCIAL
<br /> Iz#c:a f� .a�;�� it kls), .U it<y:r z , .?�, ..,c:c=lsz at .-,ia.J <.n_.};t,, ;c,:1,,<,I and.`itaEe rt<:_.:.,1 J ,px,sJ3a�at, -.•..,r �.,_ '_,,, ;iuv`
<br /> any ,Icd <a:-z.r i.a,. of y :,:�,,a.:,< , i;t.,,;l,�s_<€ S I's<a c,ttC&pt£ro,t,itis"CN€s;,rz:rn::;tt.
<br /> VI.I_T'GAI,NO'l Il IC.'AI ION AND 1511_;..INN r1I;;_?1''.I',SS
<br /> Chc"k"_tIRE IiOX fi,f t,.; k0ill
<br /> TANS,OWNER ORA f lli.M z 't?.L;:1'< ��: ;,�I; 'I VtE: :'SitsJ�, �1;31)A I: TI Ii hC)1L3<.i51 C1AC.:A€LI)
<br /> (a)(13){.} "(' Ia.,f 23{ II-Y:T[;Ri 16,CAt..II t:)1C IA C:t I E OFRECIt.L,k"TIC)!'S.I
<br /> D,rSTR,UCTI l•OR'-1'111'.LOCAL AGE N{::T'S
<br /> I7rc c :.niV art,t ,sz<i i,�,^nizJ.:x Il,t ';,..,,;n,,,4nd cr.t be, n-thined by call>a2g,the Sir€v Iloa.rsi tae
<br /> asst rc'by t1 t c I an n y lace 't. , E s a r n€ , t�tr , at :ical.and r. nnot co ntain any alpha:e t<»�,cF.J.,,,.c.rs. a tl z.`�:,i cy x A,,cs
<br /> the&Ats;Boutte.to as,zig'a uhe facill0v^<<.J._bc ,pic se weave it blank.
<br /> IT is 1:€ 1 I StTis 31:.:1 z 01:1 L(,)CAL AGENCY'Fl1AT INSP C k:S T119 FACILITY TO VERIFY 'I"III: AC:'t_ -:RA(., 'OFTHE
<br /> LN1 01.11 ";> t) I "i"II'�Al:1._ z € ,ti ;;?I :;I
<br /> -'ROCP
<br /> t'FSSED IFTHE BOF ACC0UN"1`NC.IL'I13LR IS NOT FILLED IN, 131T LOCAL
<br /> L
<br /> AGE,NC Y iS 2t.SPON` BL,Ls IoOR ;}sI C<)"f13 .1',)N OF THE 'LOC'AL AGENCY USI: ONLY'INFORMATION I3OX AND FOR.
<br /> FtORWz; )LNG ON 1{ ILaX" ''ND ASSOCIA It FORM"I3"(s)'TO THE FOLLOWL'tiG ADDRESS, THE LOCAL AGLNCY SHOULD
<br /> Rl .11 111 OR,16*1 ti A,.S ANI)I ORWARD"I'IaL YELLOW COPIESTO TIM FOLLOWING ADDRESS,THE PINK COPY SHOULD BE
<br /> RI::i.�T\T;II i1' ITIi:i (MA'I:R.
<br /> 3'93 FOR0120RI
<br />
|