|
INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SE TION 2711 OF TITLE 23,CHAPTER 16;CALIFOWNIA CODE OF REGULATIONS AND SR:TTONS 25286,25287,ANL?2-5289 OF CLIAPTE-R
<br /> 6.7,DIVISIO" 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE C3L'vNERS TO APPLY FOR AN LIST()PERA"IVNG L'EiT mrr.
<br /> 1. One FORM"A"staall be completed for all NEW PEFZMI T CFIANGES or zany FAC IL IT°'YlSI'£E INFORMATLONr CtIAXGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a FacilitytSite,ta: ardless of she number of tanks located at the size.
<br /> 1 This toren should be co npic.ted by either the PFILMIT APPLICANT or the LOCAL AGENCY UNDERGROUrN``'D T ANE,INSPECTOR.
<br /> 4. Please type,or paint clearly all re quested infornouion.
<br /> 5, Use a hard print writing a orusnent,you are eta akzng 3 cojliW s,
<br /> 6, Tank owner crust submit a fac lily pha plan to the local s£_cncy as hart of tht application showing the location of the US"Ts with respectto
<br /> buddio,gS and l ndnl Iarks(Scuion 2711(a)(y),C RJ]
<br /> 7, Tarek owner enlist staltzrart doerassentatac>ra shoursnt,ccs rr,2 a..Ve ,,?cls state financial responsibility requirements 20 te'ioea3 agency as part of t4ze,
<br /> application for petisti ton USTa a IS;ctcon 2711 (a)(I I),C'-a;,,
<br /> TOP C3E F ORNIi "MARK ONLY O ah.ITEM"
<br /> Mark an(X)in the,box reextto h%.;tern that Ix,,st dcsaribca tl,',reason tree,Rain is being completed.
<br /> I. FAC..TL-iYISI E LN aaC7tiiM AT'ION&AD 7ak1.SI(S(MUST BE CO1tlssLF,I-ED)
<br /> 1. Record na-r e and adc.Use(physical J,Ix atiaon)of€Pae;undergresurtd tank(s).
<br /> NOTEAddress Sluvs,r neve a valid physical location including city,state,and zip code,
<br /> P.O,BOX` T_,'MIlI-fRcS ARE NOT AC`CEVi'ABLE.
<br /> T,- 1 I ds neaa < c rots st ev1 and tralne c:#the operator,
<br /> 2. Phone number must have an Ines c<xic, if the night nurnber is the same,w6te 'SAME"in proper location,
<br /> 3. Check the appropinite box forTYPE YPE Ol'B SINESS ONVNER.£SITIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4, Check the capprupri alt.box f"Err TYPE 01,T3L SINFSS.
<br /> 5. If FuaciIity,S;te is located within as Indha.r rWsnrvation cit other Iridian trust lands,check the box rna:kcd
<br /> 6, Indicate the N I:sBER of TA_` KS zt,his SSFTF,
<br /> 7. Recrad tZ ET.A,IU O dor write"NONE"in the space,provided.
<br /> IF, }'1TOP11i'Es''I Y OW°,;rts°I'x¢CFz211ATION&ADDRESS( U 1131:C O s11'L I`ED)
<br /> t ornp?'let"',all iterate in this sc°caisa ,rat.'ess all iteins are the swnc as S C110N 1,If the same,wrac"SAME AS SITE?'across this,,oI-`om Be sure
<br /> to check P1I0 I,1'R'a x°CyaA'NERSHIP`hYPE box_
<br /> I'll,TANK a3Wi4,.IZ INFORMATION&flLT;lRESS(1,I;SS1`131
<br /> £utnplcF c.alt ituni,t.3 thk azo lio.l, all ,n„s are the same asSEC110N I,N`tire, .ansa,write sANII_.AS SITE. u.Os,.Ie.sa ct,on, lies sum
<br /> I%,BOARD C?:' .'.,L.`tl_., ON t S€ S i OR A(31 a 1,1.AC C()1,'`,,f,lit 1s9131ii(SfuRl Bl.C.cJ°s.Al IA i ED.SIL All"l IC L!i 5,C_;IAVI I,rp a,.1-5
<br /> i II.S,UN 20,CrtIJFOIPM A HEAl_`I'll A N?SAFETY CODE.)
<br /> F.t. r yore,?Sx,.:rei ca `.,.a i,tat�car.(13ti,i".,t IaST stesrag E e,as count n.t ers3�,.x�1>,s rug a..e,t t: linea y tu�r t lett a.,Ink �!on c a_,.>
<br /> Rcgi,tration ,iih0kcl'3C)7 vs,h s.,aar t`'iat}'c>n w t receive a Su.a;t.caly storag Eco r t€acct irn rcapc,rEirag rhe S;l t=;.rs{€iv ai ,¢'� '.,na:.rPn tF.e
<br /> n Issuer I,e gallons c.,s c in�a ,r 'He,BOb wiH Code I mon paying the st"'TaSe fc,. .,tOM ...<, b-, ,, ,._ 11"yOu donot
<br /> to the SOL,vn ti,c .at.russ P.,.,,�,of l:c{"ral,xaFiw.t,Fuel"axis Division,11,0,Box 91,28 ae, ." �.< .,kfa ,CA >
<br /> V. 1'13"11COLT. IMt.w;a"i°1\.xNIC'Al,R1Si£.;`asiBIlsIY('MU TBLI,C:"CdMP1,11tIIL}FORI'EIR(ri11'NatSit. CN ',5,.:, i::£ I1£.?"'S 1Ia;<<;l
<br /> OF 1.ILF 2t,S.IL-sPIl:b E'S,CA! �IORIIS.Af;£? r.£}i ICE;£it;I S°TS.ON&)
<br /> Ta n,, Ino.a...tl.tn, , UI,od; dfc ,^,vn,s aitdlha cIpe a or,in recta ing the Federal 3_1d Si Klm,u ,. .ai as illi era,=_�<ty r ,.i.,t.a:1 .Fk Us 1 s 1�y
<br /> any x edcra;u,StMt wg as to ell as non-petrol um USI s sang exempt frown his z res._na nt.
<br /> VI.1wEGAILN01I}a"''AiTON AND BILLING GT ADDICI=;SS
<br /> Checl;ON F BOX for Ific"addlcss tt.aat will by used for F3t3TH LEGAL AND 1.3I1 IANC N(J I'il CA 1 ft_FIIS.
<br /> TANK ONVNE OR llw'l:it RIZI D RI..l1I2IIS1,,NT'ATIVF.MUST Sl('3N AND DAT SHE,FORM AS J1ND£.A i'FD. ,SD: ., , ON"',.w?I 1
<br /> (a)(13)OFTI 23 CH AP I LR 16,CALIFOR-dA CODE`3F REGULATIONS.]
<br /> I.PrS"I£SUCTI N FOR`111,LOCAL AGENCIES _.
<br /> The courtly at,jr J,,d�ction r mbCrs arc prcOeterrnisted and'e t be obtained by calling the Safe,floafd 0,116)227-1303. The a a W tlily rtlaIrecr srQa;be
<br /> assigned be the local agency;ho%k ever,this number mustbe nurnerical and Cannot contain any a*pn 1,e7Lic al characters_ 3f tr: ls;.al zaga_r_;,P lifers
<br /> the State Board to as :gtt tho,f acility raurnber,please leave it blank.
<br /> IT IS 1,11!_ RESPONSIISILITY OF THE LOCAL AGENCY TFATINSPECTS THE FACILITY TO VERIFY THE AC CU'RACsY O1= THE
<br /> ItiFr£".1F£Si.A'i"FC}Y. l`I'i.S ,AI'l'1.1CATlt`a C A \£3 T BLPROCLSSED IT T}pE F3C'}l ACCOUNT St. 1131.1?.IS NOTIJT,I.ED IN, '1111"LOCAL
<br /> AGENCY IS RHSI ONSII IJE. F(t, Tiip COlti'i,ffl'1"ION OF THE "LOCAL AGENCY USE ONLY" I Irf?RMATICON BOX AND I OR
<br /> FORWAIU ANG,OYv 11FOR _ A"AND ASSOCIATED FORM"B"(s)TO T`ZIE FOLLOWLNG At DRF'.SS. TIIE LOCAL AGENCY SHOULD
<br /> RI;"IAIN"IIIE ORIGINALS AND FORWARD THE YELLOW COPIES TO TETT'?FOLLOWING ADDRd SS.TIIE PINK COPY SHOULD BE
<br /> REITAINE'D BY'TalE TAINK t)A4'1vER.
<br /> ST'A'TE.OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO:S W sF:.E,z.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3193 FOR012DRI
<br />
|