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INSTRUCTIONS FOR. COMPLETING FORM "All
<br />Gl"INERAL INSTRUCTIONS:
<br />SEC IT()\ 2 711 til ITI LE" 2:3, Cl 1AP I ER 16, CALIFORNIA CODE O%REGULATIONS AND SEC;°DONS 24286, 2528 7„ AND 252189 OF CHAPTER
<br />6.7, DIVISION'C), CALIF()-N.JA HEALTH AND SAFI.-,Y COD;. REQUIRE OWNERS TO APPLY'FOR AN UST C}I'];RATING F7PRI11T.
<br />1. One I`t:iRM "A" shrill be completed for all NEW PE;it^,IIT CHANGES or any FACILIT Y/SITEi IitiT'C)RMATIC'sN CHANGES.
<br />2.taSIJBI IT ONLY ONE (1) h€ R1,M "A" for a IracilitylSiw, regardless of the: number of tanks located at the site.
<br />3. "]'his fount should be cotrlaletcd by cithur the PERMIT APPLICANT cur the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. please type or print clearly all requested infonnation,
<br />S. Use a hard point writing instrument, yon are making 3 copies.
<br />6. Tank owner must submit. a facility plot Plata to the local. agency as part of-the application showing the location of the`USTs with respect to
<br />buildings and hmdmarkc [Section 2711 (ra)(S), CCRI.
<br />7. Tank. owner inust submit documentation showing compliance with;state fimurcial.responsibilhyy mquirements to the local agency as batt of the
<br />application for petroleaatn UST's. [Section 2711 (4)(11), CCRJ}
<br />.TDP 0i°T FRIM: "MARK C)?et.,xi ONE, I S"I>M"
<br />Marie an (X) in the box next to the heni that best describes the reason the forn't is being completed.
<br />1. FA€ ILi I Y/ST 1 l: INF'OILMA`i`IO ck ADDRESS (NIUS r =3L COMPLETED)
<br />1. Record narne aid addles (physical loc,.atio€s) of the a ndzreround tank(s),
<br />NOTE: : Addre ss NOUS T have a valilk,physicA location as including; city, state, slid zip code,
<br />1).O3 13OX N1"NIBEILS ARE, ,SCC f,1yrA 31>E;.
<br />Include nearest cross street wld name of the operator,
<br />2. Phone number mmt a°de ase area code, If the milia number is the same, writ; "SAME" tet proper location,
<br />3. Check the appropriate box for TYPE Cllr TIUSTNESS OW NE.I2S]IIP (ex, CORPORATION, INDIVIDUAL, etc.).
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Fac dityJ;Snc is Is caved within an lmh n reservation orother loo ian t.nsst lands, check the htrx marked "YES" `
<br />6. Indicate theNUMBER y. BER of TAN]CS at this SITI?.
<br />7. Record the I .ia-A, ID # or write NONE" in the space Provided.
<br />11,
<br />Complete; all items in this acctk ca, mflcsiR all itcins arc the s<arne as SECTION 1, I alae Santee, write „SANIE AS SITE" E" <acro> %titin ,..case aa. Re .;tare
<br />to check 11ROPFRTY < WNEIRSlil.'1'YPIi I,,>x,
<br />IIL 1ANK OWNER I"el°OWMA ION & ADDRESS (411 S 1 r31. COMPLETED)
<br />Cowes k-,c �)
<br />all iter's
<br />.(itgtflcs secllion, a css all items are the sarne as SEC. i` O 1; if the same, write "SAME AS Ss e L" <across this cectiersi. Be, sure
<br />to ct cck t fti'+-lS ERS Yi .. box,
<br />IV, BOAitl i OF i::Q rel_,IATION -USIF 4 i'=`)I AGE FEE, AC.t(NT NI MBE'R (NIUST BE C:C)%lial.ETI,,,D? SEE AR I iCI.E 5CliAl'S S".R 6,75,
<br />DIVISION 20, CALIFORNIA HEAL-I'll AND SAITTy C:i)h)I .)
<br />Exact }ou;!t ' rd of Etj al,i,,niu a (BOH' 1 i sw aas;c fee accovmt nurnberahich is retluire'd aforw your N it <a; ptic.)cik>n ::a , latc>t r.a4er<t.
<br />Rt gi, t, at iola at . l= frac BOF u i l u, ;h:. , s.. t0rcceive a eivasterly sto age fce rc a run in rc poythig the S0 ) )h (6tt it 1—; ;,....t, I-due on, 0he
<br />atu ntxcr tat gta'u tai pla,,.,3.n �<nat -5 hs. "l €a., >:,C) uiil coc:c Ix is tt ex ts:}at:frvaaa Parisi tftc� sue :iyc t,:c st, r ?aa,s;,. �r,i., .,.::.., +. ,f �,ou do art;
<br />lat(: an account numbu v i h the; 11,(:)13 or if you have any questions regarding; the fee oT exettalat ons, pic,ase caul the 13t 1. <a: I.6, 3'22 9669 orwntc
<br />to the BOF at tste, follo%x ME;adalr zss I3o::raa of Equalization, Fuel Taxes Division, 11.0. Brix 942879, Saacraaxa ulo, CA 91279--)01,
<br />V. Pl?:leC)Ll:CitiltiS t' FINANCkAl- RESPONSIBILITY (All";S'l, falx i:f)Ml'hi. ]'?a) FOR S''tw"l`tt{)i,C.0 Ya IUSI's ONI-Y, SFE SFC i'zf(JN i ,. 719 (ra)(h)
<br />IC, C,Ahll OICNI;i t:',?DE O IZEGIULAI IONS,)
<br />Ides t uy the lncthkxl(;) a+,ed by rhkc soawr caa;l;cor iia s,ievtmg; the Fedcraf and State financial tt la.arasii,if,ry ,el',jL aa. ,.1 S r s o nt. d by
<br />any l cdc(A or `ai,ate.abency t p : p ; '
<br />,as wt�ld as s�aata c,sxca�¢t,:sa 1. S"]"a taretwesir t frc;tta tram. tertatresYncnP.
<br />VL LE(3A].: OT1114f'ATION AND BILLING ADDRESS
<br />Cherh OSE: liO forthe address thaP will be used for 13( 111 1.1<C,Ai A�l)131.L.L S�Cz rCY'S`SIaCC.° V"f [d:7�
<br />TANK OWNER <)id:1(7"IT1C)Rall7.l) ]tlit'!il iIi ti"1"ATIVI: LIC;S°l` STii� AND 1) ATE'I'illi FORIM AS I:eDIC,.A I' 1). [.,,s.a; S-z,( "1'1€)" S -2 11
<br />(a)(13) OF-1'1 CIIAlyfER 16, CA111,01f�IA CODE: OF IIEGULA'l ONS.i
<br />INS"lRUC`1ION FOR 1`ll1'I-()CAI- AGENCIES
<br />The county an ) tri_;
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