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INNTRU TIONCOMPLETING #RM "Alf
<br /> GENERAL INSTRUCTIONS,
<br /> SI.0 114)N 2711 OF 1 I LIi 2.3,CHAP l FR 16,CALIS'CJR IA CODE OF REGULATION' s A:`sI3 SEC'I"7ONS 25286,25287,AND 25289 OF CIIAP`1 R .
<br /> 6.7,DIVISION 2€3,-CALI OR\IA HEALTH AND SAFETY Y CODE REQUIRE OWNEIRS 1`43 APPLY FOR AN US"I COBRA-1I.NCx PERMIT.
<br /> L One FORM"A"shall lnc°completed for all NEW PER UT CILAIeCiE S or any FA€"I,LITYISIT"E LTvFCSCLMATFC3N CHANGES.
<br /> 2.ati'lil3ltfrr ONLY OISEs(l)FORM"A"for a Facility/Sue,regardless of the number of tanks located at the site.
<br /> 3. This fonn should be cc4uplet.ed by either the PERvIlT APPLICANT or the'LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please typeor Pruni clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner roust submita facility plot plan to the local agency as lean of the application showing the location of the 1JSTs with respect to
<br /> buildings and landmarks[Section 2711(a)(S),CCRI.
<br /> 7, Tank owner must submit documentation-,hk>Wing compliance with-statefinaancial responsibility requirements to the local agency as kart of the
<br /> application for petroleum USTs[Section 2713(a)(l 1),CCR).
<br /> TOP OF FORM�"MARK ONLY ONE ITEIVI"
<br /> Mark-an'(X)int the box next to the item that best describes the reason:the fortis is being completed.
<br /> L FACILITY/SITE INF'C RNIATION&ADDRESS(MUSTBE(:C3MPL.,E;°i'ED)
<br /> 1. Record name still address(physical.:location)of the underground tank(s).
<br /> ;"OTE:Address OILiST have a valid physical location including city,;state,and zip code.
<br /> P.Q.BOX NUMBERS ARE NOT ACCtiI'°E'ABLE.
<br /> Include nearest cross's street and narrne of the operator,
<br /> 2,. Phone nu nbe:r must have an arra code. If the might number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS C)WNI.:RSIIIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropn•iate box for TYPE:OF BUSINESS.
<br /> 5. If Facility/Sint;is located within an Indian reservation or other Indian trust lands,chock the box marked"YES",
<br /> 6. Indicate the N,UMBLR of TANKS at this SITE,
<br /> 7. Record the.FT,A.11)#or write NONE"in the.space Provided.
<br /> If, E'IZOPEI I'Y OWNER ER 14`l"}14MA T[()N.4 ADDRESS( lis,`°s'T BE COMPLETED)
<br /> ED)
<br /> Complete all iturns it)that;rsectiora,urn.icss:ah hetes art~ifie sanne as SC,IION I;If the same,write"SAM AS SH'I?"across thi.,.,ecta<a.. Be sure '
<br /> to check l'(tC3:'Srl..1,Y O'A'1','",RSiTIP I`'t`PE box,
<br /> I:l.. I x NK C>la"`CER IN OR,I.°,';It) <'&A DDR' .SS(t1'U n > a`.Cb_.�IIlLF"I :l:})
<br /> C'o,anl,Ie 4,it[! terns Intin__.�,.i nI i tnicss all itl,ms aro the sa e-,as SLC,iTt,N I,It,,�c sa. �,w.ii 5.�.�,la AS Sxs:" «tints abLt. .a�;iota
<br /> IV.BOARD OF F1,71-,"A(.,(..0UN I -,NlJ.\4 ElZ(NIt.ST [3E Ct)M3'LE I ED.SEE,STI t tt."1IF 5,CIIA a I R 677,;,
<br /> DIVISION 20,CALIFORNIA I iFALTII AND SAFETY CODF,)
<br /> Inu r a'our i:lo<ar4T of 3. t<:J.z:alvtn(T3C?Laj us'l,star:af;c 1`ec ac.,ry?;nat anar,nbtx u'Inicln ns reya,ire.d lx:Iora,your 1nMssu ,,a,hi E:,n.,., .,rr.R,c r ro=cat d.
<br /> IZ,:,:,..Aannurt to an ow BOF v"611(,ar t.:.c t1'!,.son,t Avt', r .ceive a<It:aMt;rly st4>ra;,e f:, alar ora reprsrtitng tial;`0,0fel�t(rnn �„ srs dens vr�the
<br /> tnu nt>a'.rof 1;.+[liras S>ltt...al in y<nur,,w l's. Ifie[30",till code Ix;rsoans excir,pt fro n)p.ivisn,,tri, stesr:a,,t,fcc,,so return,,v� H r. Uc 1f you do not
<br /> have an.acc:cro£nrtt rnurc'h{n.r with tta; I30l3 or rf q,�)u have any questions rcE;setlirtg tfac 1cc carr-cse;rnpticrrns,ple;asts call rite MJ?;aiJIC 32, i6a J of;trarca
<br /> to tho 11,011 at the fol ,skis;<nd41 w,.,I3t..:,a of L.uual:xanoza,Fend Taxcs Division,#'.t'§.Pox e t2zl'i9,Sacra'ratlato,("A 9 12 {A
<br /> V. P11"`IR I:Ut t:US 1'1111,s. `.IAL 11.-,iPO r1 IILI°I'as (NIUS I II}i COM, Al"I t.i;)FOR ill"`it'OLh"-Al
<br /> T `3`'c.I-$_,.'_;(11AP...'r 16,C,1,13.0,�NL<CODI:s{3.F:Ri,,"G} LA IONS')
<br /> Y,.,o-savt.rr3ti up_..s t.rviH". . �i
<br /> d3 &,_t .,�
<br /> . e A>�ra- ,jS:h., r i,..
<br /> ansv _.--i.4}or€l£i :S ',ncy as st,.i#as tiolk .7 S'i>L.'.*$T7 i,:S S -�{a r,.ex�rit a 1" _Z(r Ga.. Soiull('n(w..t.
<br /> Chc,dk ON I B()X,1,c, .t 1. l`d,cs. 11...t v.I! f.,l,,cd,`or.I .I..I GAI AND I31 ,LS,t4<N01, CIA..f - ,'
<br /> .,v CtbAa`NFRI OR.A1,l i1OR1111ZE T IC}a'I'.n SF., , i I E_.N'IC;S I,Sits. AND DA-I E';ills' FOR"d.s4,i;' ?. A 6,1i? ,
<br /> (a),113)01''I ITL 23 t,,iA<'3'1 R 16,t.l,'t3.It ORNA'A CODE OF REGF U1,. C S"s.
<br /> LNST'RUC"IION FOR 1 "E'LOCAL Ar,E CIES
<br /> s.a.zn x.'are Board'('tf?' e,;;3 Tllht,
<br /> asst£.d y 111' lo-fl tE incl,h w c r,thk lIwilb,"r nlust irc t urlcii a l anil cannot�o main an ipi.,ab €lcai 1! sggc=nc, Ixlater~
<br /> the Stat lia:n a cr io assrE si the facility rn ambor,please;cavi it blank.
<br /> IT is l HII OF THF" LOCAL AGENCY TiTA I INSI'l C 1S I:IE, FACILITY E 1 C3's EIR! t -HE £CC A t, ,RAC". Cn>a"IrTr
<br /> I:SFO'RMATION, 'I'lIN APPLICATION t.:C''°NOT BE PROCI SSE'D IF THF BOF, IS NOT IILLI1 D IN, `ITIE LOCAL
<br /> 1`eC'lENCY IS lir `Il0t,S'1Bl,F FOR 'FIIE C:;C)bi1'LFITION OF<THE ""z.t)CAL f1t'siE:;vCY USE 0,NL' I.NI:( R%,1A'I'I0N ii X AND FOR
<br /> lC7lZl'v`ARD'ING ONE FORM A' AND ASSOCIATI:II3 FORM"il"(s)TO°Ellik}zC:kI.LC)WING AT?D I'lSS. THE LOC'AT,AGILI`m4`i'SHOULD
<br /> RED,1IN T11ORI LXALS AND FORWAKl DHL YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK`COPY SHOULD BE
<br /> STATEOF CALIFORNIA
<br /> 4'IA
<br /> S'ATL 'APER RESOURCES CONTROL BOARD
<br /> Q'O S,W,E:.Ea1r,S,
<br /> DATA PROCESSING CF:N`I'ER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> FOR012ORI
<br /> 1
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