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<br /> INSTRUVkONS FOR COMPLETING Awm A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711()EF TITLE 23,Ciltli'"IER 16,CALIFORNIA CODE OF RECULA`t'I.ONS AND SEC'I`ONS 25286,25297,AND 2.5254 OF C'.IIAI�`rER
<br /> 6.7,DIVISION20,CALIFORNIA IIEr'4U I I A\D SAFETY CODE REQUIRE OWNERS-1.0 APPLE'FOR AN UST OPE R<!`IISG F'Fdl,N-Tfr,
<br /> 1. One FORM"A"shall be completed for all N EW PERMIT CHANCES or any F°ACILFFY¢SITE INFORMA'T'ION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/She,regardless of the nuinbLT of tanks located at the site
<br /> 3. This for.ra shoulfd be completed byF either the PERMIT APPLICANT or the.LOCAL AGENCY E>NDE',RGROUIYI3 TANK INSPECTOR,
<br /> 4. Please type or print clearly all torIt eszed information.
<br /> 5. Use a hard point writing instrument,you are making 3 epics.
<br /> Ci. Tank owner must submit a facility plat plats to the local agency as part of the application showing the location of the USTs with rerspect to
<br /> buildings and la r,1marks[Section 2711 (a){Is),CCR].
<br /> 7. Tank owner rmiLt submit docurnentation showing compliance with state financial lresponxibility requircnme nts`to the!locA, al enc `as parrof the
<br /> application for Eictrolcum CSTs ISect=un 27 11 (a)(1 1),C'CRI,
<br /> TOP OFFORM;"MARK ONLY ONHIEH< I°'
<br /> Mark an(?C)in the box next to the I ern that lxat describes the reason the form is being completed:
<br /> I. FAC H1TYfSITE I FOR:MAJION&ADDRESS(:BUST BF COMPLETED)
<br /> 1. Record narne and address(physical location)of the underground tanks).
<br /> NOTE: Address MUST have a v=alid physical location including city,state,and zip code.
<br /> P,O,13OX NUMBERS ARE Nf7°I'ACCEPTABLE'.
<br /> Include nearest cross street and narner of the operator.
<br /> 2, Phone number roust have an arca code. .If the night number is the satne,write"SAMA"in proper location,
<br /> 3. Check the appropriate box for'FY PF�OF BUSINESS OWNERSHIP(ex.CC)RPORA'110N,INDIVIDUAL,etc,).
<br /> 4. Check the apprt)priate boN for TYPE 01',11USTNE SS.
<br /> 5. If Facdity/Sitt;is located within an Indian reservation lir other Indian trust lands;check the box.marked"YES",
<br /> Ci. Indicate the NUMBI,a.R of"I'ANKS at this SITE'
<br /> 7" Record the,E,P.A.ID#"or write"NONI,-,'*in the space pro idcd.
<br /> _IL PR011111,'RTY OWNER LNFORNIA11ON&AI3DR SS(MUST R It COMPLI Trm)
<br /> Complete all items In this section,unless all itcssrs are the same as SECTION(l;If the same,write."SAME AS SITE"across this section,tion, ,Ile sure
<br /> ua check PROPERTY OWNll,"RS11111` YP:E 1sox.
<br /> TILTANK£)4VNER INNFORNIATION&ADDRESS(NIUST BE'CC)1NIPE.F;`I`1,M)
<br /> Complete all items in this section,t., It s:s all itcrrn'are the ssrne as SECTION 1;If the name,write"SA.IF AS SITE"ac.toss this sc:ctiol). Sic slate
<br /> to chc,.k T AN K C)A' N11*R S TY PE bctx.
<br /> IV,"BOARD Oil'EQUALIZATION N f"S l S" OIZAGE Fit 1,ACC C'(:)I\T Nt 61131,.:2(Slid'In',CCJmp1 I"'IT.11 Sl-['AR11CLE 5,Cl l R 6-75,
<br /> DIVISION 20,CALIFORNIA HEALTH A\t) Y CODE.)
<br /> Fntcr vour Board of Equ al,aalion(13U1?)LSI storafte fcc account rnmme.r,al ich t,,elate°I lxfore,you pi,nrit<api Iic'.afion can Ill!,
<br /> Rcaz E,tr.tt;on sz itlr fine 1101;will e su,c,that you xili r�,ccdvc a quarterly s >rag,Ice r."a:n in rehorring d"c.SU'U 61r1,F11 , r g,dlon f^N"doe t al�alias
<br /> aloins'swcc511,,t1<�,z,s;.c€i,;tyasirL.SIs. :}ar13C1IsBrill coda persons ext;tnpticcen h.)arxb hu.tc.rag<,f„c.srs-cIa..a- xill.not ll,,<eArt. '.fyk�aa let,acat
<br /> have atl.acco'mt n,anf)Q,will:0w tilde-.cx t',stat fta any.xucnrtions Feg;ar olt;talc .ac,na ax _n,,t,cc"a s,ploasc"a,l i.,,is£ a? a:(;-?'.l f,.:;"or wY lc
<br /> to tlac;BOE al the foldou.:al!addlt _ .1uaal o i y.: =,t,ttiurt,ZFucl Taxes Division,11,0,S>)x 942"S"19,Sacswncnl.,CA 42 �
<br /> V, PIiIECC)i_a. `.'�:i"4_ IE`+ir``�NCIAl.i I..>.'€ NSIl3.¢.iT.,y{�f{,`3",BEC.(;tMP..1-lT 3Iflkdxe�I�i4l,.t,h' I �,S,. t.i 1.7>. :_a..�xc...<'._v
<br /> t)fF”1"i"l`I�..2�t,(v1eA.''hfa3lC„ C:AL:IIt):<4L�Cc},)�L%I Is.iCll)I�AI,C)i'AS.j
<br /> Jd n ify t?.0 ra cih. :fps)a,cd by the c v nor F.nd oat tilt r.dFc..,in ra tirng i.lc Fctlaral<atad Stair,a.t,..nkci =tui}"a a_ tl,t; ,tea, �w
<br /> any t ,a.c„aI cat- ag n, y its s°_xI a,nun rwuol,aunl UST-,a.0 exen-I t Relit th s
<br /> VL LFG,AL NO'l IFICATION AYl7 MILLING ADDRESS
<br /> "1(tc's.k{)SIF,I ()Y foltlw,. .d,,ess tf,.aa%sill bc, s(ed'OT BO I'll I-EGrAL AND BILLING,Is1C)I I,FICA"1ION'S,
<br /> TANK OWNER,,O'1 AUTI10R s°iiD RE111RESE.'N'A"I'1VE Mt S"'SIGN AND I3ATI "(`IIS;IFORNI AS IN:llt„A t::I), t l..:SE'C,I Is=N`217 1
<br /> (a)(I3)OFF T1 t i.3:2.3 CHAVI'lliR 16,4 ALILFO '.IA CODE£3` REGULATION&I
<br /> INS RUC"110N FORTHE EiE LOCAL AGENCIES
<br /> The county anjurisdiction nunaxars art;preletcnniated anti cuts be obtained fly calling the Slaw.Board 1916)2214301 I E.G ,.a°,ober,...,,Isw,
<br /> assigned by the to alagencu;.houes-er,this number must be numerical and cannot contain any alphabetical characti a, If the s`r"t ,<,g ncy pr, re
<br /> the State Board to assign.the flacilay riumber,pleas;leave it blank,
<br /> ITIS THE RESPONSIBILITY OFTHE'HE' LOCAL AGENCY THAT I:"*SPEeC'IS THE FACILITY TO`i1,RIFY"("Ill..ACCURACY liar`1111E
<br /> INFORMATION, THIS AI'PIIIC.A PION CA:S'e£)"l"BE PRC)Cs-E,;SED IF THE;BOE ACCOUNT 4L SfI3Z:12 IS NOT FILLED IN, THE 1,0C Al'
<br /> AGENCY I`; RHSI'€_ N SIBLE: FOR 1'111 C:"OMPLE'TION OF THE "LOCAL AGENCY USE ONLY” INFORMATION BOX Aivl) FOR
<br /> ZFOIZWARI)l'\ti O,Nl I C3RM"A„AD ASSOCIA-I`ED FORM'B"(s)TO TIIEa I,'OL,I,OWL;NG Al DRL,SS. "I`IIF I..00 AI-AGT,,NCY SSIIOII�1,I)
<br /> I21 TAIN THE.ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PI\K COPY SHOULD BE
<br /> RETAIINEi:a 3Y THE.TA K OWNER,
<br /> STATE OF CALIFORNIA
<br /> S"ETTL WATER RESOURCES CONTROL BOARD
<br /> C/o S. E E-P, .
<br /> DATA PRC)C SSL'~G CENTER
<br /> P.0,BOX 527
<br /> PARAMOUNT,CA 30723
<br /> 3.~�s F 201MR1.
<br />
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