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INSTRUCTIONS FOR. COMPLETING FORM "A"
<br /> SECTION2711 C33'-'t€TLli 2:3,CHAPTER ER 1 ,CALITFORNIA CODE OFF TtI GUI A f'F(2.NS AND SEC IN)°S 25286,25287,AND 25284 OF CHAP"F6
<br /> 6:7,DIVISION 20,CALIFORNIA 11I AL`T`Il AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR,A4 UST C PERATTNG F'1 RMI IT.
<br /> 2. StIBMI1R ONL Y'ON (1)FORaH M"�A for fear a Facility/Site,I regardless of the numberGES or any of ra ranks located lat the
<br /> �A�C1�C".'t°IAd�E5.
<br /> 3. This fotnsshould be coniplet d by either the PERMIT APPLICANTor the LOCAL AGENCY UNDERGROUND UND TANK INSVEC FOR,
<br /> 4. Please type lir print clearly all requested information"
<br /> S. Use a hard point writing instmrnent,Valu ate making 3 copies.
<br /> tri, 'Tank owner must submit a facility plotplan to the local agency as part of the application showing the location of the US"1`s with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCRI,
<br /> 7. Tarik owner must submit documentation showing c9dipliaanbe with state financial responsibility reguiretaent.s to'.he loeaal'agency as part of the
<br /> application for petroleum lJ':"Ts[Section 2711(a)(I l) COR
<br /> Mark an(X)its the box next to the'it-con.that best descrPoes the reason the form is being completed,
<br /> I; FACILITYISITE INFORMATION&AIyDFtl SS(isUSIi 1313 COMPLETED)
<br /> L Record name:and address(physical location)of the Underground tank(s).
<br /> NOTTE: Address MUST have a valid hvcrc.al for,lion including city,state,and zip code,
<br /> Pa O,BOX 4G-NM13ERS A121 C}`I ACCEPTABLE.
<br /> Include nearest crass street and name of the uperaton
<br /> 2. Phone number must have art area axle. If the night number is the same,write"SAME"fit proper location,
<br /> 3. Check the appropriate box.for TY PL OF BUSINESS C14A%NE.RSHIP(ex,C ORPORATE],N,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPL
<br /> OF BUSINESS.
<br /> r
<br /> 5. If Facihtyi.3ite is l€caitrd within an Indian resen,aation or other Indian trust lands,check the box nuirkod 'YES",
<br /> d. Indicate the NUMBER of TAN S sullies SITE,
<br /> 7. Record the l:.i'.A.It)#car wrne, NOINE"its the space Provided.
<br /> 11. F'l2()I'Tm12TY OWIN R F4F ORMAI ION&Aa)DRESS(Mu,S`t'11E C(')MPl<L^^'"IED)
<br /> Complete all items in thas section,Welles all' tans are the stone aas SEC710N 1;If the same,write."S AME AS SITE—across this stiction. Ile sure
<br /> to€lieckl'12011'F,,R'rY C1Witi La,RSI Ill'`I'Y PL box.
<br /> ,Ill.TANK OWNER INFORMATION&Al7DR SS.(N4UST T3I3 t:f941PLE''I ED)
<br /> Complew all items in this section,unless all items are the same as SECTION 1;If the.sarne,write`SAME,AS Si I I:"across thk wctidari;,Be sire
<br /> to check TASK C)A'';ERS"f``r'11L lac>x,
<br /> 1V.13C5Aidly C)lF l:()Gr~ti_IIIt 10(14 tS`i':i'1'C)!t?+(sl:CFI:I°:AC,EMC7Li4'1"15(3�I111:1t(�7LlS T liF:i C':C)�ATIaI.Ts`t 1�1 i.5:1.1?<Al2"I'f(:"I..l,:�,t'il;Al''I"ls`R Ei.' ,
<br /> DIVISION 20,CALIFORNIA 1I1;ALTII A411 SAFETY CODr.)
<br /> 11-ntex}oul Hoard of hl'qusl"r,.atiun(BOE)Us"',mirage fee account numberwhich is iquircd before,your ixanrit arplicag ,n_an ti,-,
<br /> Rcgi .at€ori%vi6i th,'BOH ss letl,"J.:l i, you will receive a quarterly sic mgc ft e ru'atum in rer oa ilw 0m0mSi7..,}C>{tr,t;' :;t�>„tw:�, .," >aa ti�<.
<br /> ,,
<br /> S 1`ti. The.,G. xi,i1 code Fx rsorta exc:ntstfrcan paL`it'>the etc c fc.c sc>,-W H", ;. !...,,.a. „i. l4.-voc ,A")not
<br /> hair.as..ccoaant nuhlbc.r with tate BOIL or at ybu have;any questions regarding the€cc ur t xe mptieaaa..,plc a,;.cal w "2116 1221 96u,)
<br /> to t,ac,B(Al.,at d.e f011o"n aiig addr„ss 13v"sird c;f Equalization,Fuel Taxc5 Division,P.O.Box 912n741,>,.a_,ri n„L.cto,CA 931.27<-- t.,.
<br /> V. PIiI1C01.l?,L"\T t751't•L\i\N(i IAt Ri1'SI'C}4S1afi11,1-1`Y f,NIuS"I`a3li(",ON,tl)l.l,"1'hhP laOR l'+l;I lLOT,l�l_".a t S"F',I ti1N I,y,Sl`i3 ,ra.t:i T(7�4>�11 ( ;",)
<br /> Cyla '11.t..w'.3„C:.1.l�Al'1`lik2 11'i,Call..lht}I24I�'t C`{}C>la:.C3!°I�I:(ztL�.71<?I">i5.}
<br /> Ideraify tlso nwtlacxl(s)uscad,by the owner and/or operator,iit anceting the Federal and Staine financial tcgF,xiO)ilits -crp u,ni,. , ,1"'s i;o .,..a b
<br /> ally Federal of Ststc,sad oncy as well as non-peitolct.,n USTS are exempt,froin this tcz;uhCmcnt.
<br /> VI.LEGAL NOTIFICATION LAND BILLING ADDRESS
<br /> Check ONE BOX Ior the address Haar wiH be used for I3t?TH I,IIGAL AND I3ILLIN 4t)T II ICA I
<br /> TANK C)A4"NER 0IR r U1TIIORIC.l'.I7 f l?1'IZ(:SI:4'I"AT'tVl 41L;S"1`SIts4!s�t3 DAT "I'llE 3rC RNR AS 1NI')ICA i H1 I.;,..: ;..t 1 itttil 2-l"i l
<br /> (a)(113)t9F I"Lli 23'C"IIAT'"I`hl2 16,CALI1FOR'SIA CGDE OF REGULATIONS.]
<br /> INS"T1 UC7110I IFOR IIIE LOC;,AL rACrENCII S
<br /> The county ata sted ction tient xx rs arc prcocternined and can be obtained by calling the:State,, oa (��
<br /> Mi16)'22 t"4301 1 he our.. , nwn)b a may Exs
<br /> assigned by`the local agency;however,this number must be,numerical and carmot contain any alphabctfcA cha€ac tars. II the kxx. al agency prof,)rs
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS"1THE""2l:SPONS11.311:TY COIF 1111; LOCAL AGENCY CY THAT INSPECTS"T`I'IE FACILITY '1'O I-1UF`f"1'F.E ACCURACY OF"IITE
<br /> INFORMATION. TI W3,APPLICATION CANNOT BE PROCESSED IF THE BOE AC:CC.)Ci4`t"AL"AMi:>12 IS NOT FILLED I4, TTIF',LO(-'AI,
<br /> AGENCY iS ICI:SI'O SIl3LF;FOR"Pili: CO0 'APL T-FC3':ti OFTHE, "LOCAL AGENCY FIST' ONLY” INFORMATION 13OX AND FOR
<br /> F=L?tsWx'AiZDING ONE FORM"A"AND ASSOCIATED IrC)RM"l"(s)TO THE FOLLOWING ADDRESS, THE LOCAL AGENCY Y STIO1'- D
<br /> FZe;1A:N 1'111;ORIGI-NALS AIND F0.RWA D THE YELLOW COPIES TO THE FOLLOWING ADDRESS,TIM PINK COPY SHOULD BE'
<br /> RE"TAINED BY1 HE"TANK OWNER.
<br /> STJVI'E OF CALIFORNIA
<br /> STATLWA-11R,RESOURCES CO-14TROL BOARD
<br /> CIO,S Ak,L.F,m.
<br /> DATA PROESSIZG CENTER
<br /> Pa O,BOX 521'
<br /> PARAMOUNT,CA 91723
<br /> 3.95
<br /> FOR012ORI
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