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<br /> Ads&
<br /> INISTRUC •
<br /> TIONS FOR COMPLETING FORM "A"
<br /> G :NE RAL INS-FRLICTIONS:
<br /> SEC1!ON 2711 OFTFITT'123,CHAFFE'B,Its,CALIFORNIA CODE OF REGULATIONS AND SECTIONS252186,25287,AN'D25289 OF CHAPTER
<br /> 6,7,DIVISION 2"),CALIFORNIA HFAL.T.11 AND SAFETY CODE REqUIRE OWNERS TO APPLY FOR AN UST OPEIRATING PF',RMIT.
<br /> 1, One FOR'Nl"A"shatl be completed for ail'NFM PERNUT CHANGES or any FAC III'rY/SITI-'IiNl,'OlkNlATIia N C11ANGFM
<br /> 2. SIMMiT ONLY ONE(1)FORM"A'for a Facility/Site,regardless of the number of ranks Iocatcd at the site,
<br /> 1 This Tom should be completed by ckh,q the PER.N11'r ATIMCANTor the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4, Please type or print c1carlyall requested infonnation.
<br /> 5. Use a hard point writing instrurnent,you arc 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 Landmarks)Section 2711 (3)(8),CCRJ.
<br /> 7. Tank owner must submit documentation showing,compliance withstate financial responsibility requirements to the local agency as pan of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),CCRJ.
<br /> -1COP OI:FOIZM "�IAR1CO-,TLYONL1'1'1-,'M"
<br /> Mark an(X)in the box next to the itcrn that test describes the reason the fonn is Being completed,
<br /> NFORMAT ION&ADDRESS(Ml.,I ST BE ICO M PI-ETED)
<br /> I. AC111, Y/STEM I
<br /> I
<br /> I, Record ntlate 1ky,-_mioe)of the Ln&�rgroond tank(s)�
<br /> ; Address NIUST have a va!;sl physical lew,ion includilig city,state,and:zip code,
<br /> P.C.133X NU'.MB1.,RS
<br /> Fld'udc neau"st Cross mtrect alld name of the oilcrator,
<br /> 2,
<br /> 3. Check flee appropriate imx for TYPHI OF BUS1NI,.,,SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.),
<br /> 4. Check the appTopriatelmx for TYPE OF BUSINE'SS,
<br /> 5, If Facil4y,,'Sto is located>vihin an lndi�kn resmalion or caherbidian trust lands,check the box marked`YES",
<br /> & Indicate the NUMUEE,of'FANKS at this,SITE'
<br /> 7. Rcccnd the 1,.T,A,ID Is or write"NONE""in thuspacc provided.
<br /> Completell iterns in thissCction,unles";all itcm-,are alae same as SFC'I`ION 1;l(the satne,writ"SA.),"11I AS SITL"' this s,,,c6c-,n. Be,ure
<br /> to check PRODERTY OWNERSHIP TY11i"box,
<br /> 111,TANK OWNER INFONIA TK)N&.ADDRFSS(,mt!s,r Bf,'.comm,i,,nD)
<br /> Comohlo all ilems In lhis seciiun,umless ail iu,5ns am lbe same as SECTION I;If tlle,sanae,write"SAMF AS SITII`acro.x,thas slx'tion, Be s"I'm
<br /> .-hcckTAN*kOWN'IST'I`Nbox_
<br /> DIVISION 20,CALIFORNIA HFALIJ I ANT)SAFETY CODE,)
<br /> Entcr vo u,Board of 1.1audi;,, 6,wu US'Tsiorave fcc account number NO-ich i,,�rquired befom your�V�Tn,Q sirl,
<br /> g licalion,: ..ac proc" .<'d
<br /> Rvgi,tmtion with 0_11c B"I"I"wi'! that you WMI rcQeive a quarterly steage fee nuun iIl rqporting tIm-,SU"Y06(6=rifl,,,,)P;., fco d6k,on dim",
<br /> tlumlocr of gablons placi,dl in your Lis i's, The 13011,will Coale Nnsons exclnpt frontpayeiul�ffil, A,Or,apC(`, 0�c� 0,11
<br /> SIS<m�do nct
<br /> 11"we,anaccount Immbcr with the BOI' or if yoll have any questions regattling the 1-ce,(It CXcyupdong,pleasa call flic BOIla 916 3211 9669 or wtite,
<br /> to the BOE lit thc follcmi,ng ad'hCs's Boam,of I"'qualization,Fuel Taxes Division,P.O.13o,(942b79,Sac:Ta,-m,,w,0,CA 9-1279,010011,
<br /> V111-"FROLEOMI I.,"S roR P1zrKoT1'1',fU,Nl f"S'I'l ONT")",SEIFI S .ON
<br /> 0 F'I ITI.F',21, 16,CALIFORNIA('(lf)),"OF REGIA-M IONS�)
<br /> Ica crat ify th-n-m)"lA(s)u,ed by the<lomet and/or oporator,m,n,.l"cung tfle Fedl,:ral arid State financid Ily
<br /> any .AgClicy as well as nasi-pcnaleum USCI s am exempt froln,this
<br /> V1.LEGAL,NOTIFICATIONAND BILLING ADDRESS
<br /> Chcck-ONE UOX ior flic,,iddress that v4fl be used for 110 FIf LEGYAL AND BILIANG NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZI,"D RI,'PRISF',N'fATIVE,MUSTSIGNAND DATII�FIIFFORM AS INDICA1 1SE'l: 11()%S I
<br /> 01,111`11,'23 ClIAPfER 16,CALIFORNIA CODE OF Cif GULATIONS.1
<br /> LNISTRUC11ON FOR'I'll"I,OCAI,A(IENCIES
<br /> The nunifx.is are predetcaninedand can be obtained by calling the State.13oard(9 16)22'7 4303, 1 lxz truer ver luay bc
<br /> assigned by the lu(,al agcney;howuvcr,this number must be nurnefical and cannot contain any alphabetical characters, If the,local itg"my prelcrs
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT is 1,1111, R[1'SI1O\1'SIl311d`fY OFTIIR LOCAL AGENCY IIIAT INSPECIS THE FACILITY10 VERIFY THE ACCURACY OF THE
<br /> INFORNIATION. THIS APPLICATION'CANNOT BE PROCESSED IF THE BOE ACCOUNT NUM111,'It IS NOT FILLED IN, THE LOC
<br /> AGENCY IS RESPONSIBLE FOR Tllfi, COMPLI-TION OF THE "LOCAL AGLNNCY USE ONLY" INFOK,,,4`IATION 13OAND FOR
<br /> FORWARDING ONI",FORM"A" AND ASSOCIATED FORM"B`(s)TO THE FOLLOW NIG ADDRE'SS, THEI.00AL A(3ENCY SHOULD
<br /> RETAIN 'Llfl;()RIOINAL-S AND FORWARDTHE YELLOW COPIES TO THE FOLLOWUNG ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINE' )BY'l H'TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL 130ARD
<br /> Clio S,W.E1T�S
<br /> DATA PROCE SSD,1 G CENTEIZ
<br /> 11,0,BOX 527
<br /> PARA'
<br /> NIOUN'J',CA 90723
<br /> FORD12ORI
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