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INSTRUCTIONS FOR COMPLETING A RM "All
<br /> Cil"INERAL INSTRUCTIONS:
<br /> SECTION 2711 011-ft"I'LE,23,Cl tAP11R 16,CALIFORNIA CODE OF RF',GU'LATIONS AND SECTION'S 25286,25'2117,AND 25289 OF CBAPTER.
<br /> 63DIVISION 20,CALIF()R-NIA HEALTH AND SAP ETY REQUIRE OWNERSTO APPLY FOR AN I-ISTOPERATING PERNII'L
<br /> One 1"OltN4"A"shelf be coniplated for all N EW PERN!ITCHANGES or any FACILITY/SITF INFORMATIONCHAN(7sLS.
<br /> 1. Y3131'alITONLY ONE(1)FORNVA"to,a Facdny/Sir,,,,regardless of the numberof tanks located at the site.
<br /> 3. This fomi,should be con'tpleted by either the HRMITAPPLICANT or the LOCAL AGENCY UNDERGROUND TANK INTISPEC170R.
<br /> 4, Please type or print dearly call requested information.
<br /> S. Use a hard point writing inloruntent,you are making 3 copies.
<br /> 6, Tank owner must submit a facility plot plan to the local agency as part of the application showing the location(4 the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCRI.,
<br /> 7. Tank owner must,submit documentation showing cornpliartee with state financial responsibility requirements to the local agency as pact ofthe
<br /> application for petroleum U'STs(Section 2711(a)(I 1),CCRI,
<br /> TOP OFFORA4�'.NIARK ONLY ONE,ITEM`
<br /> Mark an(X)in the box nest,to the item that best describes the reason the forth is being completed,
<br /> L FACILITY/SiTE INFOR-NIA110N&ADRI,,SS(�,,IUST BE CONIPLEITD)
<br /> 1. Record nanne and address(physical location)of the underground tank(s).
<br /> NOTE',: Address MUST have a valid physical location Including city,state,and zip code,
<br /> 11.0BOX NUNIBERS ARF,,;6'r ACCI,,'1y1`AI`l1J-,.
<br /> 1r clsadcz nearest cross Street and na=of the opcoaor.
<br /> 2. Phone number must have an area colle". If'the.niph,nurnl-,,cr is the same,write"SAME"in proper 1;,scation
<br /> 1 Check the appropriate K,).N forTYPL1,OFBUSTNEISS OWS1,"RSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box foiTYPE OF BUSINESS,
<br /> 5.If Faci,lityjNatl is located within an Ind;an,rclarvation or other Indian mist hinds,cheek-the box marked"YE'S',
<br /> 6. Indicatc the NUNIBLI(ofTANKS at this SITE.
<br /> 7. Record the 1,T,A.ID#or write"NONE"in the space.provided,
<br /> 11, PROPE'RTY OWNER INFOIRMATION&ADDRESS(NIUTST PL:COMPLF-IT,D)
<br /> Complete all items in this section,ualcss all items are lhcsame as SI C'DON 1;It the same,write"SAINIE AS SITE`across this Secticxl. Be,sure
<br /> to check PROPERTY
<br /> 1,11,1 ANK OWNER INFOR.MAION&ADDRESS(MUSTBF,COMPLFTED)
<br /> cornplet-all ilems in,thi5 uldcss 4,1 it,nnl,,arc,i.ho slania,as SEIC11()N 1;It Oic sarne,writ; "SAMI'l AS, tctogs thk scc,16ov, Re llurl-
<br /> to cbcEkTANK 0�S',N-Ei5STYPI� h<,,x
<br /> NumBlii�cvlus-r�,m�COM""'In 1,1),sim ICIA
<br /> IV.140>AM)OF j�QCATJZATION US.-S1 OSM'd'�,'ITFACCOf -ARI. F5,CHNI)TER0,75,
<br /> DIVISION 20,CAi,1FOR.\JA ilFALTH AND SAIT,"TY
<br /> yow (B011i)U'ST'Storage feeal:courtt rturnbcr,,O-ich as requircd N,forl�lyk)ur P�+nnit aplplicw�on :,m be proccx',ed,
<br /> %vath lhc BOF,will enswe that You will rccervea qkumerly stmago fee retuni u,,re'roaing the`^£J.X)6(Om ) fcc due on the
<br /> fCa do not
<br /> 1hu 1301",will Code,Nrsons exempt fium p,iying LhC 1,,
<br /> If Y<Al,
<br /> have,all acCollln nlifilln'r with the;BOE or if you have,ally questions regsndirlg the fcc orexcalldons,ple:aa.tail lh11,0k,w'9 16 322 9069
<br /> to the 130E as,the folio, Mg adds,ss Board"'I Equ'lli"'ation,Fucl'Faxes Division,:.Cl.Hw<942K"9,Saciw�-Wlm,CA 91,. ;;`001
<br /> V, IIETRO'11UM""S I'l,1,NANC11AL RISIIONSIBIIJTY 131-1 USTc ONLY, SF(71'ONS27t 1 nll(S)
<br /> I
<br /> OF11 CI IAPI'Ek 16,CALIFORNIA C'01)1;Of Rl�,GVLAI 10.NS
<br /> L!cnlic6-ti _ail by N', tha Fcd%nial eel Slate financial tv
<br /> y
<br /> AND I31R-LING A,DDPESS
<br /> Cat c(AONEBOX'orlh �ld4eslhllqt vlit bca:ed1klr1q0TII",l,"CALAND IMLIAN I G Nfl)111-ICA"ON'S"
<br /> TANK OWNER OR AUTHORIZ11`13 RI,PKF'SHNTAI'1VF AND DATEIT111-F010-A AS INDT
<br /> ICAi'D, JSI`',SI�CAIONS 2",1
<br /> 1 6
<br /> (a)03}OF1, LF23 C' lAPITR I �CALIFORNIA CODE OF RE ')ULATIONS,j
<br /> INSTRUCIION I'ORTHE LOCA 1,AGil,'NCIES
<br /> The county an jurisdiction numlms are;pl-edcLarmincd and can be obtained by calling the State 3oald(916)227 1301 The facdi!y nwrlbcr may Ile
<br /> assigned by the local agl,,ncy;howvvcr,this number must bc.nurne6call ar)d cannot'contain any alphabetical characu,"m If'the,local agcncy prcfQrs
<br /> the State Boaid to assign the facility number,please leave,it blank,
<br /> ITIS THE RESPONS111,311ATY OFTHE' LOCAL AGENCY THAT INSPECTS Tlll.," FACILITY '10 VERrFY'I(IF ACCURACY OF Iflfl,
<br /> INFORVI,A,110N, Tl I IS A IT LICATION CANNOT BE PROCESSED IF If IF BOE ACCOUNTNUMI-31'.1I IS NOT]I LLF DIN, '11113,1SKAL
<br /> AG1-'.NCY IS KJISPONSIBLF FOR NIL, CO3MPLETION OF'1111i, "LOCAL AGENCY USE ONLY" INFOR'VIATION BOX AND FOR
<br /> FORWARID'�NG is NT FORM"A`AND ASSOCIATrEf FORM"B"(s)TOTIIE FOLLOWING ADDRE'SS, THE LOCAL AGLNCY SHOULD
<br /> RETAI"; I lar.ORK3INALS AND FORWARDTHE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RE'TAINE 1)BY')Ili;`L'AN'K OWNER,
<br /> STATE OF CALIFORNIA
<br /> S-I ATE WAIT'R RESOURCES CONTROL BOARD
<br /> DATA PROCESSING CENTER
<br /> PO,13OX 527
<br /> PARAMOUNT,CA 90723
<br /> FOR012ORI
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