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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENEINAL INSTRUCTIONS:
<br /> SECTION'2711 Cabs'I 11 ,E 2 3,Cl IAPTE'R 16, ,ALIFORNI-yA CODE OF REGULATIONS AND SECTIONS 25286,25287,xAND 25283 OF CHAPTER
<br /> 6,7,DIVISION 20,C:AL.IFOR'NIA IIFAL`I`ll AND SAFETY CODE REQUIRE OWNERS-1-0 APPLY FOR AN UST OP RA'l"ING Pl F.Mm
<br /> 1, One I°C}RM"A„shall be completed for all NEW PERIN11T CHAING S or any FACILITYISITE TiNFOR..h IA'110N CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks looted at the site.
<br /> 3. This fortis should be ctnnplet d by either the PFl2.tv11T APPLICANTor the LOCAL AGENCY UNDERGROUNDTANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information,
<br /> 5. Use a hard point writing instrument,.you are making 3 copies.
<br /> 6. 'rank owner must submit a facility plant plait to the loeld agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711 (a)(8),CCRJ
<br /> 7. Titnk owner angst submit documentation`showiai elstasplian with state financial responsibilityregatircemecits tri the local agency as p a,et of the
<br /> application for petroleum US"l's[Section 2711 (a)(11);CCR),
<br /> TOP OF FOR-',d!"MARK ONLY ONEITE-114
<br /> Mark an(X)in the:box next to the stens that best descrilbes the reason the form is being c ompleted
<br /> 1. FACTLITY IT€:tit FRIM ATION&ADDRESS tN-TUS t BE COMPLETED)
<br /> ED)
<br /> 1. Record name an"'address(physis a3-Location)of the underground tag k(s).
<br /> NO'ire: Address IDUST have a c alid physical icatiot including city,state,and zip facie.
<br /> 11.07'BOX INUN413ERS'ARE OT ACCEI'TABL
<br /> Include nearest cross street and name,of the operator.
<br /> 2. Phone number most have an arta code, )1 the aright number is the same,write"SAME"in proper location, _.
<br /> 3. Check the appropriate Fix f>r'S'°s"PLOF5 BUSEN SS OWNERSHIP(ex.C;ORPORATION,T,DTIV DUAL,etc.).
<br /> 4. Check the ag,pres(rsae box for TlI'IsOI'F3C SI I S
<br /> 5. If lac.aty'Siic is lox lh;(°withiat an Indian resewation or other Indust trust lands,check the hol marked y Its".
<br /> 6. Indicate the aNUNIBER ofTANKS at this SITE,
<br /> 7,desoid the ET. A.Cid#tar sir€td NONE"3n the space provided.
<br /> IT. PROPI.RiYCWNI,<RI`ea"ORMA'S,ION,'kAI>:>SCLSS>'Nslli'STIIECOMPLEIED)
<br /> C omplcte all iterns in this sccdotz,unless all items are the'sanae as SECTION'1;If the wane,write"SAME AS SITE""acros,this e3i<aazm Ile"are ,
<br /> to check P OPF,RI'Y OlVNiaRSlllls"I:YPII tXcx;
<br /> CIL`I°F�'arlCC3ta,`�LI�I�Iaf)li3flt'n`T(?�*;��,��3I1`,iZ:`���41CI5"i'lib C�O�l1'i,E'i'k;Zl) ..
<br /> Complete all heats its this section,ltnless ail iterns are tfsc;sa mc;as S1 C,°11ON 1'jf the saga e,lvnxi't F,S YII'a S �� Is`t a,:ro.,s th is s trocar:.Re,%16,,
<br /> to checkTANK OWNERSTY1 II,"box,
<br /> TV.I3€)Altl k Ola I','O AI.-dLAp'l'ION GS I,S'1'0>KI:ACI.t'El AC,C`Olsti"I`NU. NI I.:,R(-NILiS`I'T3E CO),,,Il'hI'I"Lp7.SpIL AlI*1',i(l,T,5,ff i AI <L (.7 '
<br /> DIVISION 20,CALII°E IfNlA HEALTH AND SAFE fY CODE,)
<br /> IL'nttr yoxrr Board of alar""a.r x(1Cttw)U l a:orage fee acc:otant ni lnber which it rctpuir,d bt,hord your Nfsa,,a ap p i,:a ion S xr.F ..,c�:<ed
<br /> lbug tat.,atiol)wi, d this BOE'wi i c lure that y0ti t'r`ill r-,ccive la quarterly simage fee rc.tt.rri ill r'porthlg the:?�J.7 ir3�fi ��;il §.�:=`:4 i,>I,li z,:I.i,s3.,die,
<br /> : t.etru:Iiizx,,s. 5...&�.,1.ny Lir >.'s. 'llae13OEwillcod Nrsow,exeni t;remptyingtheslor:a4 B���s,a �;,_...., �, il.a,',
<br /> I
<br /> Vit„ ,.a.,. •
<br /> `[ia l',a a a.;<:ount i,luni lcr:,ith illo BOE r if you have any questions regarding the lzc cis a...s.r di:zt.a>pleasa,call.h�;13t r...,
<br /> to t.r,a3 ii tat the f�ollrr i gar,addF,,...?;s:;r "f Ejualtt"etizxi,I acl T";axe Isa�tsior,11,0,a3c;�� til� c_t.,C s� ,1y,
<br /> �:.. ?t`x.a..�
<br /> V, }'a. IROLE M US I<_ 'NCIA._,iCi.3l)0N'11lll.l'!'`r:(jt S'S 111',-C tSl'1"L i hl l tJtd i ss
<br /> 0�'111-1T3'2 3,C.`I,APi<as ifs,C;" IAI O N11A C,(`t3lit.}I Rd,(x f.'aaA TIO SS,)
<br /> Id r!,fy dho,sa<xl ex„*)u,.Cd by dl,,,owncr arld/or op tartar„in wcotul-the 1 cdw.rai and Stat tt.,.tnlwiaa<. ,t,:ns,�i .,A S'!
<br /> any Fc&,r"d tar state.egcncy as:c 11 as nim pclmil,,:,n I STs air-exernpat.frcacnthis i pcii;carrc�ait.
<br /> VI.LEGAL NO tTFIC'.AT'ION AND t:3ILI;u'G ADDRESS
<br /> Chcck ONE BOX for the acdd css that will be used for BOTH LFGAR AND BILLING;NOT(TI<.'.et"I 10"S.
<br /> TAINK OWNER OR AUTl1C31'siZlil7 AND DA1"I.-1-111`1 F RNI AS lNI J_EF SAC fl().`.S 2/'t l
<br /> (a)(13)OF TIT'I.F.23 CII PIER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INS`IRUC:11O FORTHELOCAL AGENCIES
<br /> The county tar J isdiction nuitihcrr are predetcrrydned and can be obtained by calling the:State Board(916)22, 1303. ?hl, l .,i �, a„a:nhc r nwq he
<br /> asatgned by ibe local aigcirey;howevcr„this number must be numeric aunt cannot contain any alphabctical charRacacrs. 1f the loc al..;,ene y ptrcic:rs'
<br /> the State Bozs Fd to assign the facility number,please leave it blank.
<br /> I1”IS THE RE SlSON SIi3ILIT Y O'TITE LOCAL AGENCY THAT INSPECTS HE I ACHAT Y lO VERIFY THE AC:C.i,'RACY(* 'I'IlE
<br /> INFORMATION, I"t tip AI'I'I.IC::11IC3Ayy�A,�tJr I3I PRC)Ck S aLI)Il°T1tC' I3C,)I 1C COC;,i"\L,1ii?l:t�I4`C)I i tit. t3 l4. [112.1..0'( .9I..
<br /> AGI.\C.Y S RESl'O SiI3LE, FOR THE COMPLETION OF THE' "LOCAL AGENCY USE ONLYY” IIS F01 ,1KIIO ' 13OS AND FOR
<br /> FCIRW ARDi NG CINE FORM'A"AND ASSOCIATED FORM 13"(s)-1-6 TFIF,FOLLOWLINO ADDRESS, THE L.CSC`.Aid AGE'NCY''SHOULD
<br /> RETAIN Fill,'OR GL"N"AI S AND FORWARDTHE YELLOW COPIES 1"t3 THE FOLLOWING ADDRESS,THE PINK.COPY SHOULD RE
<br /> RETAINED BY'l ill.,.''I'ANK OWNER.
<br /> SPATE OF CALIFORNIA
<br /> S"2`ATL WATER RESOURCES COTROL BOARD
<br /> 00 S, .L.F.T S.
<br /> DATA PROCESSING CENTER
<br /> 11.0,BOX 527
<br /> PARAMOUNT,CA W723
<br /> 3�
<br /> FOR012ORI
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