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CTIONS FOR INSTA,
<br /> COMPLETING "A"
<br /> Cri? ERAL INSTRUCTIONS:
<br /> al,C`l'IC)ti 27l I OF"L1`I'i.T: 3,C.I'AP-I`I R 16,CALIFOR IA CODE OF i2EGUI.A I`IONS AND SEC."I O S 25286,2528'7,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALTH AND SAFETYC'ODE.FIaQUIRE OWNERS"I'0 APP11Y FOR AN US-1'OPERA°T`UNG PER IM
<br /> 1, One FORM"A"shall cornplenid for all N LW PER1,11T CHANGES or any FACILITY/SITE I-iNFOI2MA110II ' Cal S.
<br /> SUBMIT I3MIT C3N Y ONE,(l)FC)12M"A",fora FacilitylSitc,regardless of the number-of tanks located at the site.
<br /> 3. This form should be completed by either the I'l;I2i4 rr APPLICANT or the LOCAL AGFNC:Y 111q;D1y.lWtC3UND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information",",
<br /> 5, Use a hard point writing instrument,you are raking 3 copies.
<br /> 6. Tank owner must submit a-facility plot plan to the local agency,as pact of the application showing the location of the 1.SSTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(13),OCRI,
<br /> 7, Tank;owner must sulanit documentation showing compliance with state financial responsibility re uireraaents to the local agency as Paan ofthe
<br /> application for pe.trrslcurn USTs[Section 2711(a)()1),CrCl3).
<br /> TOP OF FORM:"MARK ONLY ONE,ITEN4"
<br /> Mark an(X)in the,box next to the:itern that hest describes the reason the form is being completed.
<br /> I. CaACII.I`I"Y1SITIi INFORMATION&ADDRESS(XVIUS"S"`BE COMPLETED)
<br /> L Record name and aciciress(physical location)of the underground tank(s).
<br /> NOTE. Address M ST have a valid physical location including city,state,and zip code.
<br /> ROC 13OX N"UMJ?FIIS ARE NOT ACCEP117 ABLE,
<br /> Include nearest crass street and natne,of the operator.
<br /> 2. Ph<,ne nuTiiber sxttrst ha•,-;art arta ccxde, ,If the night number is elle starve,write"SAME"in proper location.
<br /> 3. Check the appropriate box fiat TYPL OF BUSINE.SS OWNERSHIP(ex.C=C7IC1'E RA'1'16314,TaNDIVID AL„etc.).
<br /> 4. Check the appropriate:box for TYPE OF 13USINESS.
<br /> 5, If acilit)"Site is located within an Indian retsmadon or other Indian trust lands,check the boy.marked`YES".
<br /> 6. Indicaic the NUNIBER of`IiANKS at this SITE,.
<br /> 7. Record the E,P,A.IT)#tar write 'NON II"in ffie space provided,
<br /> II. 1rItC')PE"RTY OWNER INFORMATION&ADDRESS QvIUST Bi,COMPS.E'I'Eb)
<br /> Complete all turns in thaw scction,unless all iterns are the same as SEC"."I"ION 1;If the s ine,write"SAME AS SrI`",across this section. Be sure
<br /> to check PROPERTY Y OWN ISI Ill?TY PE?xax.
<br /> lii.TANK OWNER is INFOlt:itfl"a'i()4 S,ADI>I TS">NIUST I3T CC?"vt4rl.l'I`ED
<br /> Complete all iterns in t)ras Section,unless a,l nems are,the sarne as SLC'IION 1;If'the same,write"SAME AS STI l."across this sectnar. I3c,sure
<br /> to chacrk`LANK{7W.NERS TYPE'box.
<br /> I$1,lff)riIZD OFE.C;?ClAl_CI:A ION IT'a"t`;a'I"(:ate':1,GE 1. El., AC:C"t:It s,'I°:et BIT.l2(MUSTBE CC71SI'I..ETED.SEE ARI,-11',5,C".flAlal'S'R 6,7 ,
<br /> DIVISION 20,CALIFORNIA 1IIiAL,'S'l I ANT)SAI E I'Y C(:)l.7Ti.)"
<br /> Enter your Board of i1:quAi r"adi m(1101,0 UST storage fee account number which ir,required Ixcfotc your fvmiit ahplicatwsr cm h;proccs<ed.
<br /> Iic�:g,ts,.ation with 111c BOE'wall ensure that you will receive a quarterly storage fee rownrt ira reporting the`)f3.EM(6ml l )l.t:.lAlort fcc;due ora dic
<br /> nuinbrcr of ilallonvlaccd,r.your,S I's, `Slat;130 will cock Persons.axeuipt from,paying t£s,sturage fee sew rei mis.wdl nobi , f€, ll;a<,u do nor,
<br /> havc all ac,aoltnt number with dic,13{7f?or if you have any questions regarding the fce orexemptions,please,c.:Il tll,;BOF.a+ 116 322 9,6 1 ur;l&,
<br /> to the BOE'at the f,011cax ing address Board of Equalization, Taxes Division,11.0_Bits 912S79,Sao an,,cnto,C°,t r 1279 0€)03.
<br /> V PE'-I`Rb11,'U.L'I UST I°tax"NCI�11.Itl�sf'ONSII3IIXfY(MUSTBE C:()IMPLlz"I"lil3laC)It I'T<IIvC)a.I:iC.41 t.,S'I's`(>ol.�Y, l,l l.C'I.Ca� 2"t"i l tar;J{
<br /> OF T[:1 I I"'23,CI1AP EP TG,C:AL.II°C)It.NIA CODI� ,CJI=RI7,GLJLATIONS.)
<br /> Icl r tafy t£r .t..tlac )tr,cd by the owner anit'or operator,In naccting;the Federal and State financial tcupn,,a�bility ?.4 I s i,. n,:d by
<br /> stay cdclad or St.atetalws;cy as wwcll as noiz p txuic sa b S` S arty exempt from this re�uist ra.crt.
<br /> VL LECLAT.NOTIFICATION A;eI3 BILLING At)DRE'Ss
<br /> Claes k ONIi BOX for tltc',address that ww=S'a be ta,esd for BOTH C F"GAL.AND BILLING N(.)TjFrCA I Isi7:S,
<br /> TANK OWNER OR At;"l I[t)ICIz;.;LJTCI,I'I�I,SI.� I°1 I I41<1'iCiS"I sTC`s° �til';)53 4I I;''I'Il1a.FORM AS D t.},£,A9 ED, ISEl:
<br /> (a)(13)Ob`I ITLl:'?3 CIIAl"I`ltik 16,CAtIFORNIA,CODE OF REGULA°I".3)N&I
<br /> INS'FRUC TION FOR,`1'lll LOCAL AGENCIES
<br /> The county an f to isrlic€tart nua fibers are Irrcdeterr deed and can be obtained by calling the;Stat;Roard(915)227-4 303. I he fa ,,r,y ra,an)b r Inay,=x
<br /> assigned by the localta cnq;howwevcr,this nuariber must be nurneical and cannot contain any alphabeticall saract<,rs. If the loc4l agency prefers
<br /> the State Boatel to assign the facility number,please Leave it blank.
<br /> IT IS THE''l ,SPON'SIBILITY OF T11113 LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOTBE PROCESSED 11,11E 130Is AC:C'C)trN NUNI 3 ilt IS NOT FILLED IN, `T1E l.(X-'AI,
<br /> AGENCY IS RESPONSIBLE, FOR PILE C0-,%1P1.T l'IO OF T'IIF "LOCAL AGENCY USE ONLY" I?ot°ORNOrl?ION BOX-AND FOR
<br /> FORWARDING ONE FOW%I 'A"AND ASSOCIATED FORM"13"(s)TO THF,FOI.IrC3WLI G"z ADDRESS, THE LOCAL AGENCY SII()ULD
<br /> RETAIN )Irl:OIRIGI Ad S AIND I'C3RWr`RD"PILE YI?.S.I_OW COPIES TO THE FOLLOWING r':T)T7RESS,"I HL PINK COPY SHOULD 14E
<br /> RETAINED BY]IIETANK OWNER.
<br /> STATE OF CAI,IF(JR'NIA
<br /> STATE WATFR RESOURCES CC>IY"1'ROL BOARD
<br /> C/O W.E,E, .S,
<br /> DATA PROCESSD.qCx CENTER
<br /> 11.0.BOX 527
<br /> PARAMOUNT,CA 907723
<br /> 3193
<br /> FORD12ORI
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