|
- ,
<br /> INSTR10HONS FOR COMPLETING *RM "A
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION TIOti 2711 OF TITL Ii'23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH ANTI)SAFETY CODE REQUIRE OWN RS TC)APPLY FOR AN EST OPI3RAFING PERMIT,
<br /> 1, One FORIM"A"shall-be completed for all NEW PETLIMFf CHARGES or any FACTLEfYISITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORIM"A"for a Facility/She,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by either the PERMIT APPLIC ANT or the LOCAL AGENCY UIv'DI,RGRC)UND TANK INSPECTOR.
<br /> 4. Please tyles or print clearly all r:quested information,
<br /> 5. Use a hard point writing instrument,ycaa are mating 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the US`i`s with respect to
<br /> buildings and hindmarks[Section 2711 (4)(3),CCRI
<br /> 7. Tank ownor nal,, submit docurnentacion showing compliance with state financial responsibility r`egtairtaments to the lacal agency as part of the
<br /> application forlwtrc>leurtt UST°s JS-- i:,ai 2711(a)(t 1),CCR},
<br /> TOP OF FORM."a'-I,ARK ONLY ONF ITILA,.
<br /> Mark an(}C)in the box next to the item that beast describes the reason the form is being co npleted,
<br /> L FACI:C.XFYISITE INFORMATION&ADDRESS(N41 aT BE COMPLETED)
<br /> I, Record narne and address(physical.location)of the underground tank(s).
<br /> NOTE: Address have a valid physical Irl,cation including city,state,and zip code.
<br /> Y,O,BOX NUNIBET s ARL NC)T ACC'EHY AS LF-
<br /> Incltzdo nearest cross ttr„cet and naTne of the opcf ator.
<br /> 2. Phone number trust have an area ceKie, if tha night t?t m1wr is the sa rle,write•. ;-IIS`°in proper locatietz.
<br /> 3. Check the;appropriate box fol-TYPE OF BUSINESS ONVINERSHIP(ex.CORPORATION,INI)T.YIDUAL,,etc.).
<br /> 4.Check the appropriate txrx for TYPE OFF B USINhSS,
<br /> 5. If Facilit,iSitc is located within all Indian reservation or other Indian trust lanais,check the e box,marked"YES",
<br /> 6.Indicate die N MBEIR(d TANKS at this SITES
<br /> T Record the E,PI A,Tia#or wriic"NONE"in ifirr space provided.
<br /> TI. PROPI:.R I Y C)W NEli r\'I OR'sIA IIO &A11T)P s,.S: (\JUST 131 C.OMPI.LTEI?)
<br /> Complete all herr=s ill this se'Q6on,unless all items are the same as SEsC!°ION 1',TS the same,write"SANIF,AS SITE"<acnws ibis section. Be stare
<br /> to<.hcck IrROPI�"i'Y O :4[eSt:i'TYPE:boa,
<br /> IIL T ANK<7Si`NER INFORMATION&AI)DRIESS(MUST 13L:COMPLETED) l�
<br /> C:o,npl{'Yw all i1vins ni ts'li5C a'Boll,t.r.less all items are ffic same as M9EC' ION 1,1.1 tli?",SFttT14°.wrlre.„S A��E>'lS SI TE`= acruss ihii 4C.4,i ii:Rl: Be sure
<br /> telcbL x lAN CWNIsRS tYI'Ebox.
<br /> TVBOARD 01,IIQ ALIZA'I IO x f;S 1'S-1 ORA(F„FEE"AC°C('}t,L`I''.°CL?,"II3a..s(MU I BF CONIPt.I,i'ED,`dill AR NCT_T 5,C11APT ER 631,
<br /> DIVISION 20,CAI.a.ORNIA 111,AI.T tl AND SATE'1'`a'C C)i)r..)
<br /> S itte }`anal Board of]icg_ 1h,'-Iioi.e01,01;.)1 s F Storage,fee account n: pJr,..l l.efoTc,, .s,m rniii a3p liaraiaota caxl brr �>rocesst',d,
<br /> ltegi ,r.a6orl e;i'h llie B01",c�i�m sw e.fl%,l,you z i111 tc,,—ive c..F a"at:rly s",at,e ice,t W au.r it r-Ir nrr'a1,t..e� ),,s t_n,Jk) d1on fe,x dui,c n darn
<br /> nuan'a..r of gallons p"I'c?,,1,our US']S. I i. 13!)1 o di code.her ens cxe,,npi["grana, .yi.r,g the stor,q f 2c so yo i&i not
<br /> lr3ve as account nurn,:,v. "t,,(c,�(,.;err Y ali.es6ons rcg,reim g 01r,cc..ur cax.=t�..ic>.a,plc ansa call'l i3C), a,9lo-3 2 c)ibil or v rite,
<br /> tothe.3v31I at tllc o)llas„�.I adds iss Br and c,. Equalir,,t"un,Feel Taxes Division,P,O,Box it, fIs;S�ctarties€a.,C.:,•1 942z"s 00011.
<br /> V:
<br /> arty T cd.` Tad or S...c w"ui,:y.a,".,"c,.a�;K)n 4' u l;urn t1 STs rare ,xewflE from this roquirorrient.
<br /> YLLEGAE.N0111 CATTOtiANT)11111NN(lrADDRI>SS
<br /> Ch€cL ONI",BC`t`r'.f€arlh "2da"-,01a,W01. for BOTH LEGAL AND BILl.T"e;Fl;miOTI}rlt`fC1ONS,
<br /> TANK OWNER OR AUT!It}II1ZF t I;i'i 7,S t'. `1'A'I'IG'?;Mt STSIGN AND DA'I E THE 1`01QVI AS 1I DIC Ai'I;D, I'l I`SE(7 I r{. `S 2111
<br /> (a)(13)OFTF]I1" 3 CHAPTER 16,C AL iFORN[A t"C}DL O' REGULATIONS,]
<br /> I S"fR C1TtaN FOR 1;I1 LOC~r"alr:AGENCIES
<br /> The tetunly call be obtained by calling the Staw Board(916)227 4303. lfv, facd:iyrn,.,..1 'r inay,
<br /> _assigtr d by the Racal agc.tcy;lti ca,.vti,,,ibis n-Umbux inust be numerical and cannot contain any alphabetical characters. Ifthe local age.mty prefcr,<,
<br /> the Stare Board to assign:the Lic.i it.y irumbe ,p case]crave it blank.
<br /> I'F IS"I IME.RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPhC:"TS THE FACILITY TO VERIFY THE ACCURACY OF'11111'
<br /> L F]JRAIAT ION, THIS APPLICrS'TTON(:ANSOT BE PROCESSED IFTHE 130L"ACCOUt°T 9t;i BI,'R IS INOT FILLED IN, THF LOCAL
<br /> :AGE'NC"Y I4 ISE:]sl't>N`_IBLE1 F()1C THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE,FOICI "A"r1ND ASSOCIATED FOR "B"(s)TO THE IFOLLOWE G ADDRESS, TTIE LOCAL AGENCY SIi()L1'LD
<br /> RETAIN`IIl 010(31,AT..S AND FORWARD THEYELLOWCOPIES TO THE FOLLOWING G ADDRESS.THE PINK COPY SHOULD BE
<br /> REIAlNED 13Y 'll!E TANK ONVNER.
<br /> STATE OF CALIFORNIA
<br /> STATE°dv A'IT R RESOURCES CONTROL BOARD
<br /> C/O S.Vv.1 E,P,S.
<br /> DATA PROCESSING CENTER
<br /> P.O.TIOK 527
<br /> PARAMOUNT,CA 913723
<br /> 3;93
<br /> FOR012ORI
<br /> Y
<br />
|