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INSTRU%IONS FOR COMPLETING A&M "As'
<br /> ,GENERAL RAL INSTRUCTIONS:
<br /> SECTION IO v 2711 OFTITLE,LL.23,C IIAP'I I R 16,C,ALIFORNTA CODE OF REGULATIONS IONS ANIS SECT IION S 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA IIEALLII AND SAFETY CODE REQUIRE OWNERS APPLY FOR AN UST t1i'ER ZING I'M)411
<br /> 1. One FORM RM"A"shall tx completed for all NEW PERMIT CHANGE'S or any FACILITYISITE LNFOR.MATIONCItiA NPES,
<br /> 2. SUBMIT ONLYONE(1)FORIM"A"for a Facility/Sire,regardless of the number of tanks located at the site.
<br /> 3. This,force should be completed by either the PERMIT APPLICANT or the LOCAL AC"aLNC.`Y"ic"NI3R,F2C R6dND TANK INSPEc f'OR.
<br /> 4. Please type or print clearly all rcque tcd ira.forrnation.
<br /> 5. Use a hard point writing instrttrnent,you are making 3 copies.
<br /> 6. Tank owner must submit a facility plat plait to the local agency as part of the applicaa€ion shoeiing the'loea6bh of the US"T`s with respect to
<br /> buildings and landmarks[Section 2711 (a)(S),CCRJ.
<br /> 7. Tank owner ant: t,submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for patroletina USTs(Sect'€pat 2711(a)(I T),CC RI,
<br /> TOP OF FORM:"MARK ONLY ONE,I L E!.X'
<br /> Mark an(N)in the box next to the item that best describes cite reason the fort is basing completed.
<br /> I. FACI:I.JTY/SIDE INFORMATION&ADDRESS(MUST BE C OMPLETFII)
<br /> 1. Record narne and address(physical location)of the underground tank(s),
<br /> NOTE: Address 1SLiS"T`have a valid physical lexiatidn including city,state,and zip coder
<br /> P.O:BO NTFJ�lBERS ARF:NOT ACCEPT-ABLE. _. _
<br /> Include nearest cross street and narne of the operator.
<br /> 2. Phone number must have an area code, If the night number is=the same,write"SAME"in proper Iaca.ion.
<br /> 3. Check the appropriate box for T°YPLs Off'BUSINESS OWNERSHIP(ex.CORPORATION,TNT3I 11DLJ1AL,etc.).
<br /> 4, Check the;appropriate kx)x for TYPE OF BUSINESS.
<br /> 5, If Facility/Site is located within an Indian reservation orother Indian trust lands,check the box marked„YI:S1.
<br /> 6. Indicate the NUMBER of'T'ANKS at this SITE.
<br /> 7. Record the E.P.A,11)#or write"NONE"in the space provided.
<br /> Ti. PROPERTY OWNER LNhC)RMATION&ADDRI:;SS(_1IUST;Bf3-
<br /> COMPLETED)
<br /> Completr:;all items in this section uni ss all#reins are the sante as SI C'I'ION 1,If the same:,write"SAME',AS SII l:"across this,section. Be sure:
<br /> to check PROPERTY(31r,N ERSFIIP T c PE Nix.
<br /> IIT.°I ANLL OWNER INFORMATION NATION&ADI IUFSS(blL 51 T3E CC1�IT'I I l'Iil�)
<br /> Count let all items in this section,unless all itcans are the S.'ame as SECTION 1;If the sante,write"SANE AS SITE"across chis section. Be sure
<br /> to cht.ck TANts O\ M' RS J YPE box.
<br /> IV 130AIZi:)01 EQUAl ZA'I'TON S S'IOIZAG I l Ii AC COUNT NL:MBFR(MUSTBE CONIPLETED,S13E AR CICT,13 5,Ciwraik 6,75,
<br /> DIVISION 20,CALIFORNIA ORNIA III::l1.I'il AND SAFETY CODE)
<br /> I r t<tr your Iio.ar a of,Etat 'tr,il;on(I O E)Us I storage I've account nurube r tchil-h is required txfuret yrs.,y�;,sttit altl+ticitsts'trt can be lira>cessct<4,
<br /> wr"lnnmit .��L 1;a.L ntsr e 13`dtt your dj h S I's.ole t vo 3(litt rocaive a quarterly s o.age f:e re urn in repc.rt;£t the ad;,at rx t.>rt,tIl )PO t;,dllon late`du on alae
<br /> I I.,will code I,,rsons.xeinpi frotn payirlg the stor,ag I c so`rc r pl,wiil,not�t ,cnt, if <xet acct not
<br /> has. an is vont n rr thct s EF,ilii:t;{) or it utu have#ally questions regarding the tea orexc nr rltiuns,Please call J10BOF at 916-322-900)or w�riw
<br /> torhe BOF at tt_c T,)tlov,sg ahlrr,, s Board v#E(luatiea6ort,Fucl Taxes Division,11,0, 3orn r;12879,Sactarneura,C..t 9,4279 0001.
<br /> V., PI TRO1 1 T SI �S t IINANC IAL,iii > ONSIII L.I"I"Y(S i 'I"BE C.f)ail'I-E'l-ED FOR PE-MOLEU,\! S�sk,ST=I3 I.C.'I�ICiN` 2"l
<br /> Ol T'lTL?,23,tIt 1,1I.IZIC,(.,�I..IIU:ZN7ACE3L)IaC)IIZIsC,lal,�Llt.)eS,)
<br /> Id:rtt 1g tr t-ct r Itsl r;. d by;tie Detinet attd`or opcsr.ator,in n'tcaltirtg the Federal and State f.mriciai tc.pc,cstj>;at,y s:a ui;crttuttts.L l s<,uttcct€> t
<br /> any T�,dur ,er Si ode agc,i"c.y as Well 3a aaon�-lvtrolcurn USTs:;arc excarpt.from!his requiieracr;t,_
<br /> VI.LEGAL N€y7:1s1CATION AND BILt.ttiCl ADDREI SS
<br /> Check ONE BOX for time address that rvill be uscclfor BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK Oft NEE OR AUT1101OZED REPRE.SENTATIVS MT ST SIGN AND DATE THE FORN-1-AS INDiC.ATE'D.�[gI [:Sh;C"hIt) 2711
<br /> (a)(13)OFTITLE'23 CIIAI.1TR 16,CAfjj-'ORNIA CODE,01 REGULATIONS.]
<br /> INS'IRUCTTON FOR TI HE LOCAL,AGENCIES
<br /> The cot my art Ir rrs it tion rt trtttxrs are predetermined and call be obtained by calling the State Board(916)2271A363. lbe facility nurnbe.r may be
<br /> assigned by the local agenc s,ho.sever,this.nnmber.must be numerical and cannot c:ontain.any.alph by ticalxaiaracterq:If the,local,agency prefers
<br /> the State Board to,assign the,facility number,please leave it blank.
<br /> ITIS Till'
<br /> l
<br /> LNFORiI 1'lt)l rC THIS 1I�i'If OF TTI, LOCAL AGENCY THAT INSPECTS THE FACILITY LC3 '4`ERIVYTHEA(:CURACY C)Tt "I"It13�`
<br /> A I ION CANNOT T BE PROCESSED IFTHE BOE ACCO UN I IS'C,MAl,R IS NOT FILLED IN. TIIj;'L0(',AI:
<br /> AGENCY IS RI SI'C3NSII3L E FOR THE COMPLETION OF THE "LOCAL AGENCY-USE ONLY" INFOR A`FION'BOX AND FOR
<br /> FOtR4LARIANG ONE FaOR!�I `A"AND ASSOCIATED FOIC I"B"(s)TO TILE FaC)LhC3WIPvCs.�f.I�IS3�II�S'T`ITE 41)CfIL`ACiFFICY�skTC)[I,I)
<br /> Ftt:'L'AIN Ilii:C>RI(,I.N,11.S-ANIS FORWARD THE YELLOW COPIES TO THE.FOLLOWIiNt's.,t�DDRF� S.THE PINK COPY SHOULD 13E ,
<br /> RETAINEID B #"Illi TAMC OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BO
<br /> ClO s.Yar.L:.E.P:,a.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOA 527
<br /> PARAMOUNT,CA 90723
<br /> 3'93
<br /> FOP4126M
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