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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERA,L INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER lei,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS 10 APPLY FOR AN UST OPERATING PERMIT,
<br /> I. One FORM"A"shah be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORM"A„for a Facility/Site.,regardless of the number o;tanks located at the site.
<br /> 3. This form should be completed by either the PERLleIIT APPLICANT or the LOCAL,AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly al i requested information.
<br /> 5, Use a hard point writing instrument,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 of the USTs-with respect to
<br /> buildings and landmarks[Section 2711 (a)($),CCR].
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2719 (a)(11),CCR],
<br /> TOP OF FORM: 'MARK ONLY ONE ITENt"
<br /> Mark-an(K)in the box next to the itern that best describes the reason the form as being completed,
<br /> L FACILITYISFIT,,INFORMATION&ADDRESS(MUST f3'E3 COMPLETED)
<br /> L Record mama andaddress ph,.sicral location)of the eancerground araLss}.
<br /> NOTE: Address MOST have a valid"phye-Ical location irc lu:far,city,stale-Ind rata cisde.
<br /> RO,BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Tnchtdl neatest est os sire s and naarr=e of the opcolnel,
<br /> 2. Phone number rnea_,t have an ti,,. a cc.,e. 1"the 1.0ht r,..aa' " i � a sit,"SAME"t_. ;r r au;:.r to atic ti.
<br /> 3. Check the .primate box f"<r,n PE,OF BUSINESS 0V,,, ',i,,,cSHlP`ewxa C O.'R.s"t,.aa,,rl i if N,INDIVIDUAL,etc;,),
<br /> 4. Check the ap;roar-te box aoa,T L a E OF L UST SI°L°SS.
<br /> 5, If Fa alit J„Site is 9.car,x&traria t ua lads n x_.,".s aa.on of,otticy yqllb,n Erus,ian _.check k albox marked-1 E S`
<br /> 6. Indicate the N I .,3EER ? C,'\ a a,dhis S1 a E
<br /> 7. Record t.e E RA.ii)S , „ E`in the space provided,.
<br /> Il. PROPERTY O?3'SER atsFOEM 3"isi s,<. (MUS1 RF
<br /> Complete all heals in thi. .. 6on, .,1 :S a.a it-lot are.the sanic as t;)= 1;If fhc,snme- ".,A.,4E AS SITE"ac es thsS section, Be sure
<br /> to cbeck PROPERTY 0 y.'RSIR , ,hams.
<br /> III.TANK OWNER I''FOR,,'"A IOC 411 `,-A R S. �1AdL r.E_C)4 E.. 6`Fi)),F q
<br /> Complete all items s e tht.—,,..,.Car, Tess a ,,?.. .a, r. t->sr.. as E"C E I, N 1;I lh�e�Sa a1v, vlite`'.A AS s E i ff across tlos sectio n. Be,entire
<br /> IV.BOARD O E f E,s"L ....,'NO'N L,1 a OR AG',.,,vn A(`0`)-,;--h, , 1. .,1Fs , ,,. ., ST egl_;CO'f.t L.E D,51.E.ARTIC L.,E 5,CHAPTEii 6.Ifs,
<br /> DIVISION 20,CALIFORNIA HUE'ALTH,ANDSAF1 CODE,)
<br /> Enter your Ro,and of Eq at.ra,'fio n(BOE);.'S(sto aze f-ac,"clunc aat.ntbcr which is roquilcl bcb)re your permit alaplication caf Ese processed.
<br /> Re,-;soatioll with thv 3L0h wl"!cv,,,uro vnu ufl -'Myllt the per galion fee d itL on the number of
<br /> Sellers p lac ed r ;)ln 'U"S_s, a a.-x ,.c,& .,on a xz.em n t suti s ,as to,.r=c,at,°fle",so:eltms s will rtat be sent, if you do,not have an
<br /> act^3u,a,.;nm.rnm. lr, _,:=s;,.„. a r if ti€lu L, q u..�,, c °a 1i ay it,,_,”nr e 4 rq.ions pleaspleasc sail tho BOE at 916 72, -9669 rnr wl-ite to the
<br /> BOE,.t,he:i'c'lou"hn", C's tinaai l quail,oriur Fee i 11`i,",ey'DM-io-- B..X. .'S u".arr e. nc,CA 94279-0001.
<br /> V. PETIIC)I.,EUINi UST E l'.9.n>NC IA EST1.')N 31B1L1'I y'€,a f_, i fah a )NTPLI IID I r)s.Epi`E tdt ai.EUNI ( STF,ONLY,SEE SECTIONS 2711 (aa)(I 1)
<br /> OF TITLE 23,CHAPTER 16I.sE r J
<br /> C RNIA CODE O REGULATIONS,)
<br /> Identify the method's'uscd by the o, nt—,andirr opprat=ur,itis meeting t§s.,F d ra€rare State firnmicial Yesponcibiiiry requitvments.USTs owned by
<br /> any Federal or State aa<,a act as Well ai'non ,Qt.o.narr 111STs al-4:a. -�rnr t t_c,n Ethis requi-evnepol
<br /> VI.LEGAL NOTIFI n IO "N'D -_ A
<br /> Check.)NF,130, 0€.a.. ,a till be I'lecd fw, BOTH L.EG=AL.a.a U BIL,=..,. c a La`l a t"Ads.
<br /> 'FANri OWNER R OR Ars a H RIi'..D „,RjS, i S'a;.N AND 1), FET E FORM AS INDICATED. SFE;SE?EC' `JON S 2711
<br /> (a)(13)OF”"I L,. a 1. ..Il': . ,CALIFORNIA;i7<NIA CC D1-.-,1. REGULATIONSJ
<br /> INSTRUCTION FOR ' sF L,C:nr 1.AG ;a3,'f
<br /> The county andjulisliction numl)trs are k€rwrleternb M and,can be obtaincd by c;,',isng dhe State Board(9l6)227-4303. The facility numbermay
<br /> be assigner;by the lty,,�al agevcy,,a,aswti,'a>th_ .uoibca .,,_._« C nurnlw"i zl and r anitot contain any alphih eat;cal characters, If the local agency
<br /> prefers the;Stw c Boa.d is a the nurntr, pleasc lc,,-Ave it ylsnr&
<br /> IT IS THE 1-r,7111111"
<br /> s ,. f a TG VERIFY THE, ACCURACY OF-IH
<br /> INFORMATION,ION, TIaES Aj Pj,h, -10N c_ ,N,..F a BE,PR0t 1`S D rF THE FOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL,
<br /> AGENCY 3 3 Ra Oi ~ r " FO-1 HE C xrxIPL I IONr OF CNF '`S F1-AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGFN S ,hii Ut Lf..s.sI : TL,'C--.DRJC l;- AL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> AWL
<br /> F195
<br />
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