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<br /> INSTRUCTIONS FOR COMPLETING FORM "Alf
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 20101 ThIj 21 CHAR1111 M,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFOWNIA HEALTH AND SAFETY CODE RQUIRE OWNIAS TO APPLY FOR AN UST OPERAIING PERMIT.
<br /> I. One FORM"A"shall be compleud for al[NNE W PERMITC-Ai ANGES or any FACILFIY/SITH INFORMATION CIL-N-NGE&
<br /> 1 SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the nurnber of tanks located at tree site.
<br /> 3. Thk form should be cornpIctiel by either the PERNMIT Al PLIC.:' We LOCAL AGENCY UNDERGROUND TANK INSPECTCR,
<br /> 4. please type or print clearly all requetto-d bTorn nefiral.
<br /> 5. Use a hard point wraing histrammmaou we mAWg 3 c"A,:,
<br /> 6. Tack owner mom set mh a IcIty plot plan to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings and Indmaks IScahn 2711(Q(N,SCSI,
<br /> 7. Tank owner must submit doewrienTafionshowing cornphaos�with state financial responsibility milthrements to the local agermy as part ofthe
<br /> application for Isetrolcum USTs 1&ukn 251 NXI I CCRI,
<br /> 1`OP OF FORM:"MARK ONLY ONE OT's,1"
<br /> Mark an(A)in rite box mm to we Am Am on dewnbcs we mason the form 1 being wm*md,
<br /> I. FACILITYISIFFE INiORMATION&ADDRE',SS(SIUSTBE COMPLETLD)
<br /> I. Record narac,and acids ss(physical location)or'the underground tark(s),
<br /> NOTE: Address MUST h"e a viii phy.6cai location irICILIding city,state,and zip cesfe.
<br /> 11,013OX NUMBERS ARE,NO'1,'ACCEP`FABI,.1-_
<br /> Include,moIeort cfo,"suca and maa-,€ of rhe operazoo
<br /> 1 Phone number must have m area corle, If We nQW number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate otx forTYPEOF BUSINESS OWNERMUP Nx,CORPORA'110,N,INDIVIDUAL,etc,),
<br /> 4. Check the appropriate box for TYPE OFBUSINESS,
<br /> I l( aciliVIShe it kwwd%H&an lmharr msemdon omler IMan mm lands,check the bcs,masked`"YES"'.
<br /> 6. Indicate the,NU)dHI,.'R ol"I'ANKS nthis SI'l I-
<br /> 7. Newd be ETA,IN dor write"'.NONF,,"hi thuspace provided.
<br /> 11. PROMATY OWNER iNFORMAIR)NOY AEM)RESS(MUSTBECWMPLETUD)
<br /> Qwgine all hems in Ods sectio q rmless all hems are No omm as WCUON 1;If be sante,write"SAME AS SITE"'across this recta on, Fie scare
<br /> to tweck PROPER"I'Y OWN bIRS1111"I YPli lwx.
<br /> IILTANK OWNE'R IN'FORNIATION A, ADDRE',SS('s1USTBE CONIIILLTED)
<br /> Cui"lrue all irons in Th;sechon,imless all itrans are,Me same as SECTION 1;If the same;write"SANTE AS SITE"across this switIn, Be sum
<br /> to checkTANK OWN[JASTY IIH'bos,
<br /> IV]WARD 00 EQUAl 1ZA`IUFQ UST SAMIAGE flat ACCOT:N'I Nf,.-NME.R EVIUSTBFC'OMPLE"I ED, ARTRI,E�,CIIAPTER 6,75�,
<br /> DIVISION 20,CAIJI()F,NiA li-EALTI i AND SAI,',,,-,'i'Y CXMEI
<br /> Emu I,w Wom 5 anon QQ UST Oven Von aw"m iwmkr wWA w nq &NOw you pnnn qyk Wo codw pfwyoo'i
<br /> n*nWro1gQm,pLu_wdhywuf,S4 The BA,wit!ccs deptwins ox 'nm from Pgog Ac q."S Nov)moms , bawl &j.dowt
<br /> hast,ata Rom . AACQ-t. � lits
<br /> wdw B(Am Ac Mkwmg Ada"Bond of HquaAmIN Far]Tmes Dkiston 111 Bm WAwnv,,UA QQ0 rV
<br /> V.
<br /> any!%KIM(a Sine agwu;y,,,s rvcU as non pcm)�L�rn US,!S rare escn,dpt from this rcT6Ir,,nicmt.
<br /> VI,LEGAL NOI x? ICA AND BUIAEV3 ADDRESS
<br /> Check ONE BOX for th"d&"s Am mT be and for BOTH LF,GAI,AND BILLING NO",111"ICATIONS,
<br /> TANK OWNER OR AUTHORIZED REIRESE.NT ATIVE',MUST SIGNAND DATE THE I'ORM AS INDICATE11 jSI,',F 2711
<br /> (911 OF 111IR 21 COMM ER 16,CALH;ORNIA CORE OF RFOULVI INNS.]
<br /> INS'IRUC"RON FORTUE,LOCAL A(;ENCII",S
<br /> llac comayany"kdwthmnabnoarc pm&wndmdmdcans lira oNEwdbycAWgtit„SwmBo?td(9M)2274301 Thefulloyrrundwrmay Imo.
<br /> assigmu by be AKA awmy,Iwo ew"this number most btinkanerk;iti and cannot contain any alt haNIVA charaue;s. If tire local agmcy prours
<br /> the Sum Bond w assign the,facOrty number,please leave it Ishark,
<br /> FE IS 'fill: RESPONSIBUATY OF TIM TDCAL AGENCYTITATINSPECTS THE FACILITY TO VERIFY THE ACCURACY OFTHE',
<br /> INF(IRIVIATRA. AITLICATION CANNOT BE PROCESSED IFTHE BOE At NUNIBI,,",R J'SNOTFILLED I'N. THE LOCAL
<br /> AGENCY IS RESNATHLE l'ORTHE CONIPLETION OF THE "LOCAL AGENCY US H ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONh�'F0jR_%1 "A"AND ASSOCIATED FORM-BY)TO THE FOLLOWING ADDRESS, THE LOCAL AGENCY SHOULD
<br /> AND FORWARD THEYELLOW COPIES TO THE FOLLOWING ADDRESS,INE PINK COPY SHOULD BE
<br /> RETAINED BY THE TANK OMAER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> 00 SMTIRS
<br /> DATA PROCESSING CENTER
<br /> Y.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3.93 FOR012ORI
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