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INSTRUCTIONS FOR COMPLETING "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 O T"I'T'L.t 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 2.5289 OF CHAPTER
<br /> 6:7,DIVISIO!s;20,C'ALTI OWMA HEALTH AND SAFETY CODE RI.-,QUIRE OWNERS TO APPLY FOR AN UST OPERATING A`F'ING PIWRA
<br /> 1. (,)no FORM A"shall be completed for all NEW PERMIT 3ClIANCsES or any FAC JT'YISETE INFORMATION CHANGES.
<br /> 2. SUBNMITONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be cormileted by either the PENIN1IT APPLICANT or€ e LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or print cteaady all,requested information.
<br /> 5. Use a hard point writing instruanent,you are.snaking 3 ca mus.
<br /> 6. Tank owner must submit a facility plot plan-to the local aafc.acly as past of the application showing the location of the USTS with respect to
<br /> buildings and landmarks[Sermon,2.711(a)(T),CCRt:
<br /> 7. 'Tank owner must submit documentation showing tannfilian e with state financial responsibility requirements to the local agency as part ofthe
<br /> application for petrolcom U STs ISectior 211.1(a)(T 1),C aR(.
<br /> TOP OF FOR-Nt:" IARIC ONLY ONE IT ENI"
<br /> Mark ars(X)in the lx>x next to the teem that bcst describes the Tea.on the form is being completed,
<br /> I. FACILITY/SITE INFORMATION&ADDRESS(MUST 131,CO MPI,ETED)
<br /> 1. Record name and ad l css(physical Ic cation)of the:underground e mk(s).
<br /> ,NOTE: Address MUST have a valid,physical location including city,state,and zip code.
<br /> 11.0.BON?,UMBIERS ARI?NOT ACCET"FABLE.
<br /> Include nearest cross street and name of the operator,
<br /> 2. Phone number must have an area code. If the night number is the same,orrice `SAME'°in proper locations.
<br /> 1 Check the ipprop,iatc box forTYPI7,OF BUSFNIi,SS OWNERSHIP(ex.CORPORATION,INDIVIDU,AI etc.),
<br /> 4. Check tire appropriate box for"CYTE OF BUS INES&
<br /> 5. If Facility/Site is Ioc:acef within an Indian reservation or other Indian trust lands,check.the box nuarked"YES".
<br /> 6. Indican,the NUMBER€,f TANKS at this SITE.
<br /> T R cool the l"P.A.11S a or wine"NONE"in the space provided,
<br /> IT, PROPERTY t3WNI-'R IN!�OR,MAT"ION ADDRESS(MUST BE COMPLETED)
<br /> Complete ll41 ixcrns in tll s section,unless all iterns are the sainc as SFW£EC)N 1„If the sannv,writs. 'S ANIF AS SU'h`across z6sa,:recti a. Be sore
<br /> to c°h ck P1 OPER,l"1 OwNi�11%siflT'TYPE linx,
<br /> ULTANK OWNER INI"ORNI.t[rO.` rr Alfa RI"Ss
<br /> Complete all ner.,;in this sccfion,tmnles. .ail:w rss are,the s.anse as SLC n10" .,IP t ree sa€e,wotc S.'?ME AS SI-I'll"across rlla,scc;ticsst" Be sure
<br /> to check`i ANA OSy NE-ItS TY1'Ii box,
<br /> TV"BOARD 01,FIQUAI ITIZA'i70\ S ` 0i�A T'FFI.ACC a; l `sI"MIU.l t, al., ! 131:?£{l iP't..t.lt,�.SI.L AR I'I a F 5,C:fr.sx <s'.k 6 75,
<br /> DIVISION`0,C_A H2O `i `,li
<br /> Aill:A1, .1ASALE'IY£C3L .)
<br /> nl cc y,m,l d of za e>,n t0;)Us I'stollige,fee ax,'Coa:nz ills,,%er%shs.h z rcq.x�cd brt e �r r,Ai—o Ai—oF. a .F, lac t .;x.
<br /> R , t a i<n .z<:th, HO:ll,£1.,.,.tile,t,..t you ys.;1 rc ccive,a quarterly storage f. rt vas r In rcaponala ihc,,S','-106(u i pey ka i;t',rc c.a ,s,Llseu
<br /> pl xx,ca o,-,,our a,x 3<. S tae BOE u-ill Code;�mowa e x��r,,>t .cls.p ayinz,tire stol atS ,,_o,,.,i
<br /> base a;a a€;. ,a_a�irtar,at'3err"uiLtr a.ab.rti>: rr d}<az nacre.am:y c;am�sx>r ams rc t,axda,.�. 1,��c c car cxa,n,pt;>t ,,e'. ,,;, �.,t,<.=s It➢.. ,_ : � .,'_-P`. . . < _v I
<br /> V, I E ROI,� : v>< =x_ .x x x=. r m.. 4 �< [; a ,.x n, :, ,.�.
<br /> z 's1 .. `n,l1s.,."�;,E?z,st£l:e�.a3p„xI :.,C.C}'sxr t_T.It`.aa a f£P.:..,mi>E I;i ym L, I_i; �1.', .a. Ni` ;S'rt <). .
<br /> e'r
<br /> 1
<br /> y?CJ,f a.�.e S�.ate rte S s,._1a as s.,ffl pc;ros a.r.LS"I's.are xcrt,iat faom,.Sis 3t
<br /> V1.LF"GA',N(JJ., R `ATI0'ti AND
<br /> C,hcqc��k ONI;BOX for€hx,alda c,s that°silt be tense-d for BOTH LEGAL AND T3ILLING NO'l� IC A t,<"NS.
<br /> TANK tiWNFR Off At,'Flit).;III:: RFPRFSIi.NVFATJVI MUST SIGN AND DA'{F i!h FORM AS';'a1FlCA' FD, !QF l ',10`�S ,'t 1
<br /> (a)(13",01-1]l l,i:21 r"'Ir'"I Il S 16,C:""LIF' il.NIA Ciii;T,O€`iZ>Cit,LA I IONS.)
<br /> The cr, .; an l7 mr t«€,axe rru n l acre predet rno ed and can hrn obtanr"d b}c dcu,g the Sat Po i-d <<u P. .m.1vi.u=„c.<,a.iti"he
<br /> assmgased }tel_ h,�sl u;,is :, °r,alsis rsuzraT rxnust rs nrscs land naa as.5,u4..atd y art �,< ax ,33,adt<=3 E ac x e a " p m„"s:es
<br /> the State li Sard to a -g t the f at,loy nursocr,please leave it blank.
<br /> IT IS THE RISI'€ Nl%i!B'I,ITY OFT111-1, LOCAL AChNC"Y THAT INSISa.CTS"T.}Ina FACILITY'10 VFRj?=Y i:TE ACCIIa RACY 01”THE
<br /> INF()ICMAIION, "11 i'S AITIJCATION CA:'tiaNOT Lai;PROCESSED IF T] BOE ACCO UNT NL.;AI BER IS Ni}T I I".J: 1) T1
<br /> IN, If LOCAL
<br /> AGF'N C'y N R-Si S tam tasr THE COMPLETION' OF THE "LOCAL AGENCY USE :SLY" IN'FO..8 AI'lON MOX AND FO
<br /> F'ORCt`ARD NC ONE FsORM 'A"AND ASSOCIATED FORM"B"(s)TO TREE FOLLOWING ADDRESS, THE LOCAL A(AI,NCY SHOULD
<br /> REIIAINI111,'ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOW NO ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY TILE TANK Ca Om NER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> Cft?&W.I.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARA "IO( NT,CA 90723
<br /> 3;93
<br /> FOR012OR1
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