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INSTRUCTIONS FOR COMPLETING FOINI "Alf
<br /> G1.11NE'RAL INSTRUCTIONS:
<br /> S1,CCTION 2711-01I1 ILE,'2:3,CI1APIE-R 16,CALIFORNIA CODE OF RFCaC7LATTC`NO AND SECTIONS 252 6,25287,AND 2.52189OF CHAPTER
<br /> 6;7,DIVISION 20,CALIFORNIA IIIIAL I'll AND SAITTY CODE RE DIRE OWNERSTO APPLY FOR AN L;ST C3F'ERAnI\1G PERMIT.
<br /> L One Ff'31i.M"A"shall be completed for all NEW P RNIFF CHANGES or any FAC LITY'ISITE INFORMATION CHANT E&
<br /> 2. .Si.JBINIFF ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of taroks located at the sits.
<br /> ;i. This forrn should be ccntipleted by either the PERMIT APPLICANTor the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4, Please type or print clearly all requested infotrnatton.
<br /> 5� Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit,afacility plot plan to the local agency as part of the application showing the location of the US T s with respect to
<br /> buildings and Iantiniarks[Section 2711(3)(8),C,:C;RI.
<br /> 7. Tank owner must submit documentation showing cornpliance with state financial r asponsibility`re uirements to the local sgencas part of tine
<br /> application for petroleum UST's[Section 2711(a)(i 1),CCRJ,
<br /> TOP OF FC?RN4a "MARK ONLY ONF I rE,;,,°"
<br /> Mark an(X)in the box next to the item that best desc;rtbes the reason the form is icing completed,
<br /> I. FAC ILITY/SITH INFORNM A`710N&ADDRESS(MUST BE CMtJMPL,P;'F`ED)
<br /> L Record name and address{physical location)of the underground tams(s).
<br /> NOTE. Address NIUST have a valid physical location including city,state,and zip code.
<br /> 11.0.BOX`U.NIBIaRS r1Td[a INOT A€..CE 1 ALF.
<br /> Include nearest cress street and name",of tate operator.
<br /> 2. Phone number must have an arca code, D the night number is the same:,write"SAME"in proper location.
<br /> 3. Check the appropriate ixsx for TYPE OF;BU5I:s'E:SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Cheek the appropriate box,for TYPE OF BUSINESS.
<br /> 5. If Facility;Site is locawd within art I lsan resery tion or other Indian trust lands,check the box marked Y"ES"
<br /> h. Indicate the Nt;N41 ER of TANKS as this Sl"i'I.
<br /> 7.Record the E,P,A.11).lt or write -\ON r"in t.re space ftkovided,
<br /> II, PRC PE'.RTY OWNER I\ ORMAI tON&ADDRESS SS(NIPUS`I BE COMPLl;'IED)
<br /> Complete all xt rns in this se ti.ota unless ss all steins are the sarnee as SECTION 1;if the satne,write"'SAME AS SITE`across this suction,, Be ware
<br /> tocheck-PROPERTY_Ciit,NE.RSIi11 `IN I_box.:
<br /> 111,TANK OWNER T";FC)RMATIO€ &A1711R1 SS(NIUSTBE COMPLETED) (
<br /> Complete all aeras in this section;,unless all it,,n as are the same as SECTION IO l;If the same,write"SAMEAS l i a l"aacrtssslith,section,, lk;nrc
<br /> to i Intek"6°!ia`K C}E4'N FIGS T°Y`PL,bol.
<br /> IL'.I30AM1)O11,'1,'QU I-!ZA'1`J lN '4 i , ,i_}I:1t a.E sl:AC,C E):N'I' atl:'>t1.31.R SEE'A I I s€1.1..,,Cull'.,'.?;€35
<br /> 1T1VJSb')N 2t),CALIFORNIA i ? STH ANT)SAH I`Y C.ODI-.)
<br /> Z`sartcr
<br /> your 111,.ar 3 of I?,au.:l°r zz;cst t 3f,li°:)L. . storage,tee account nurnbertxhich is required before your fa-',m.at.al fflio..ac.,. :,r 1. proc'u<�Cd
<br /> Rt—ist_.asion as.:h the he)I, s:"t W e.,a.that you will rcceivc a cluaa erly storage fee return in reporting the S0i.F,6 16r>:;1 ,p ,,,c;a s.x.(ce cies on uav
<br /> sss*zt+,'r of s f „t Irta: .i in ytz.rr S" ';h, .301- will code persons exeniptrfrom paying the sso nq,c f,e sts rwt�tms v;11.. =l, If you uo nc t
<br /> have,an I","ount n tnlbcr v.idh WOE or it}o=u have arty yaac,,Cions regarding the fee or cvm tions,pleas;call the l$t a
<br /> io f,t.,13�)1i:at ti,e Sulfa a.al,adT,,�„,Tc:>es c'.L.tLa;alta;ataan;F ue;l T`axcs C)avisir>aa,1'.0}_13cis oi:28a7 s,.`r z. .rii�a,t,,,(A<T �. , �``
<br /> V. I'h`iELC)..LL;;�Ii.Sl NINANCTALRE's'C)_NSlMIIT`Y(MI,':S"Pill:CO)v11'l.l.'CEDIrC7lt-1''[I"a`[Lf)Ll.. ElST' O ., t',51':F ..E.t ( Se NI <.,:5)
<br /> OF TTi L?,2111,C:I(.h'FIyR 16,CALIFORNIA€RNIA C ODI CJe Rai("IALAT IONS,)
<br /> anY,��'�-¢al ear Stat€°.gs,rtc;y as aeell a4 rz,>:,tic z tleu",a L,`1 s aa,,e�em;pt:'matt,tins t°.�atrsa�.rraer2t,� �
<br /> a.
<br /> Check t3N1 BOX Toluic Jdr,s,that w, l tic,a cd for 130 I'll l.FGAL;AND BILLING C)T FK,,A T b?;XS.
<br /> TANK OWNER 01IR<'+t:"I'litll ,zi,"It MUS"T'SIGiN ANT)DAT;TII1 FORM S I`°;DICA s€DI jSf !, ;,t,!E€r'a1a 2711
<br /> (a)(13)OF TI ILE'23 CHAPTER 16,CALIFORNIA CODI>OF REGUI-ATIONS.J
<br /> INSTRUC"I'li.}NIIOR 11fl,"LOCAL AGI.-C:II'S
<br /> The o'—Runty an las...diclio n,nulnls... „<.'i .C„te.�a'c,,;te;cl arad can be olaainesl by calling the State;I3o>an1(9 16)'227 43Q1 .a,. ...t rwn)bcy Truly
<br /> assigned by the local att , � shk ntnnbef mitis be nurne6cal and cannot con€;tn:,any alphabetical'char,t,,nor.,, is st., sc�,l )gency p ,i..rs
<br /> the State.Ilia,id to assign the facility numb,a,p case leave it blank.
<br /> IT"`IS 11111," RESPONSIBILITY €)Ir TITh” LOCA1, AGENCY TI"FIrYT INSPECT,`,, 't`IIE F C."CLITY" '10 Y'I RH-Y`111E A€:'t.'..RA(,`Y€ F IIIE
<br /> INFORMATION; 1`I;,4 Ai'i'IA .P<s ION C ANNO Talo,PROC.L:>s`al D IF`I'IPI:l3()E AC:C""C)II\`1 NUN-IHER IS',`e{.)`C I'1=,LS=,T:)IN, '1`IIIF I,CJ€'Al,
<br /> ACiI,ICY IS I0,S4't:`sSIBLE, FOR ta,F CO Ie I.f"'TIO'e OF THE LOCAL AGENCY USE ONLY" I4-3'ORNIA110N 13OAND FOR
<br /> FORWARDits ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING At tI:RE'SS, THE'LOCAL AGENCY SlFC3ULD
<br /> Rt,°I AIN TTCI;C RIGYINAE.S AND FORWARDTHE IIE Y LLOW COPIES TO 111E FOLLOWING ADDRESS.THE PINK COPY SHOULD BE'
<br /> REIAINE-DBY lHE IANK.OWNI,R,
<br /> S 1AT'E'OF CALIFORNIA
<br /> STATE AER RESOURCES CONTROL BOARD
<br /> C/o S,W.I..I1.P,S<
<br /> DATA PROC ESSLNG CENTER
<br /> 11.0,BOX 527
<br /> PARAMOUNT,CA 90723
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