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7.7
<br /> INs,rRL*'IONS FOR COMPLETING I*M "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLIT 23,CIIAPTI1-'.R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITYISITE INFORMATION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This forrin should be c,')tnpIctcd by either the PEIZMrf APPLICANT or the,LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,You at(,,making 3 copies.
<br /> 6. Tank owner must submit.a facility plot plan to the local agency as part of the application showing the location of the UST's with respect to
<br /> buildings-and 1,,i imarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner m,: :submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTS[Sccl:.,,n 2711(a)(I 1),CCR].
<br /> TOP OF FORM:",MARK ONLY ONF IT L'l-
<br /> Mark an(X)in the box next to the itolin that best describes tile reason the form is being completed.
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address mus'r have a valid physical location including city,state,and zip code.
<br /> P.O,13OX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area c(-Ac If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box forTYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If I'aCility/SiLe is I(XatCd within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBIJZ(-,f'I'A\KS at this SITE.
<br /> 7, Record the 1:,P.A,11)4 or write"NONE"in thc space provided.
<br /> It. PIZOPEWl'y OWN'ER INFORMATION&ADDRESS(MUST BE-COMPLETED)
<br /> Co-,rfipl:;te all horns in this sect on,unless all items are the same as SI-(7I'iON 1;If the same,write'SAME AS SITE'"across this section. Be sure.
<br /> j,IZ0pj:jZ,I,y 0%,ir
<br /> to check N 1:W.)I I 11`1 Y PE hox.
<br /> I11."TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> cotT,plcic all items it,this section,unless all items are the same as SFCI`1ON I;If the same,write-SAME AS SITE"across this secliyn lie sure
<br /> to check TANK 0WNI.'IZSTYPE box.
<br /> lo,"AMAIZI)0h EOL,TALIZATION US FS'I OIZA(il-, UNUMBERACCNUMBER(\IUST BE CO%,1JI[A1--FFD.SEF,AR FiCLE I 5,CHAPTER 6.75,
<br /> DIVIN 110N 20,('Al,II:(`1R\IA III ALI i I AND SAFE!'Y CODE
<br /> Filler Nuf 'BOF)LS i'� lief,)re I'll- C-�In tic-,ploccswd.
<br /> -iora c
<br /> ge vc lie ount nu
<br /> 1,01v;Ili L 11S'ItC tl-.3i ,,At s,tll r:-sive It quarterly s'onige fee ri'mm in relwrlujg the SUI-X!=`, f),:f fee,dui I'll the
<br /> nol-111, Is, 'I kC M11:',3I11 cede Ix rson, xcunln from!%Iywis, fOf',So t t n> I,fl!!101 L;�2 !VA
<br /> haN( an aciioi-jl! %I)LIh4%0.any questions reg:ir,llne the i31, as')I( Q2)00,torlAriw
<br /> BOF'o il;c Of L•.(Vatil.-kti0n,I`ucl Taxes Division,P.O.13,)N 942479, CA 912')-0001.
<br /> V. illi't k0l J'I. \I I NCIA1 I 'o,�I, j:'t'l'D FOR PEWOLFUM i's i's S il I I ).tiS I I
<br /> - Ill, [TI
<br /> O1:'1 ITI,1.23 C 11 APIF.1� 10,C 1.11 11 ZN1 A CO 1)1:OI"R I:G L.�1,A1 ION S,)
<br /> I(IL.IT i I y 1111. 11;0"Xii,$)kl.-d by I,he owner anJ/or operator,in mut ing the Fcdctal and State I i ial[C�pol; -Y I I'-(!)y
<br /> any FcI,�:Ijl of S%to agen';Y a, %%cll anon-petroleum US'I's arc exempt from this rcquiiCinci-t.
<br /> Vi.LEG3,1,11,NO DI KATION AND BILLING ADDM:SS
<br /> Cheik,ONI;BOX for the addruNs thal will be Used for BO I'll LEGAL AND BII-I,L\G NOTIFICAI 1(,)NS
<br /> TANK OWNEIZ 01Z AUTI 101OZED RFI1Rl.-',SENTATIV7 MI 5T SIGN AND DATE—fIII-'I`OR,!`.I AS INDICA'I ED. 2711
<br /> (a)(13)OFTt 11123 CI IAPFI:tt 16,CAIJI-ORNIA CODE 0! REGULATIONS.]
<br /> INSIRUCIION 101ZT1ii, LOCAL AGENCIES
<br /> The county an jllrisdictiofl fionilx,i,are pro;deLe rill ine d and can be obtained by calling the State Board(916)227-4303. 1 tic.facility number may her
<br /> assigned by the local agency;Ili-ever,this number Must be numerical and cannot contain any alphabetical charactcrs. If the local agency prefer,,
<br /> the State Board to assign the facility number,please leave it blank.
<br /> 11'is'I Ili" IFSPO\SIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCLTRACY OF THE
<br /> R
<br /> IINFORMA LION. TI'IS APPLICATION CANNOT BE PROCESSED IFTIIEBOE-AccouNTNum BE, is NOT'FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE' FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWLNG ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN THE ORIGINALS AN!)FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> R E'FA I N J;1)13Y TI I F TANK OWNER.
<br /> It.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/OS.W.E.E.P,S.
<br /> DATA PROCESSLNG CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723 FOR012ORI
<br /> 3:93
<br />
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