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INSTRUCTIONS FOR COMPLETING "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTIc11N 2711 OF TITLE,23,CHAPTER R l6,CALIFORNIA CODE OF RL^'UUL,ATIO S AND SECTIONS 25286,25287,AND 25289 OF CHARTER
<br /> 6.7,'T,)IVISION 20,CALIFORNIAIll ALTH AI`D SAFETY CODE REQUIRE Cr`"tVN'fiRS'TO APPLY FOR AN UST C)PL AT NG PI R.NTr.
<br /> 1. One FORM"A"shall be completed for all NEW PER's IT CII AIS GES or any FACILITY/SrrE INF ORNIATTCIN CHANGES,
<br /> 2, SUBMIT f)`L,Y ONE(1)FORNM"A"for a Facility/site,regardless of the number of tanks located at the site.
<br /> 3. This form should be cinnpleted by either the PERMIT APPLICANT or the LOCAL AGESICY T NDERGROUND'DU !NSPE(71°OR
<br /> 4. Please typs or print clearly all requested information,
<br /> S. Use a hard point writing uo .1.111 you arr°making I cops` s.
<br /> 6. 'Ratak owner rzust submit as lac laty plot slat)to the local agency as Burt of the application showing the location of the US 1.,-with mspect tea
<br /> buildings and landmarks(S.chore 2711(a)(8) CCR,
<br /> 7. Tank restrict must subs„a documentation showing compaltan withstate financial responsibility.requiremen-to the local agency as part of the
<br /> application-for .t.rolcurn USTs[Section111(a)(I1),CCI",!.
<br /> TOP OF FC)R2,4c"MARK ONE ITEM"
<br /> EM"
<br /> ,Mark an )in the box next to he isern that best describes she reason the form is being completed,
<br /> I. FA(-ILITY7ST'IE INFORMATION&ADDIZFSS(iIUST BH CC3hIPLE'TED)
<br /> 1, Record name and address(physical location)of the under erustd tank(s).
<br /> OTE;Address Ml-JST have a valid physical location including city,state.,and zip code.
<br /> P,O.BOX NU;v 13ERS ARE NOT ACCE I'ABLE.
<br /> Include.nearest crass street and n atne of the operator,
<br /> 2, Phone number inust have art area ccscie. If the night nuroer is€lie same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS C)W".°gL°RSIIIP(ex CCRPORATION: ITIVIDUAL,c.c), "
<br /> 4, Check the appropriate.tu,x forTYPE YPE C)F 31L Sta's`I SS,
<br /> 5 If I ac Iny/site;tg lccau d v,Olin an Indican reservation or other Indian trust lands,check than box mark:d"YES".
<br /> 6. medicate the NIJNI131`R of`IAN'KS ILthis§3 17— '
<br /> '7. Record the,EJI..�,Ila#or write"NONE"in the spat c Provided,
<br /> II. PROPERTY OWNER RNFORNIATIOvs&ADDRESS(MUST Bi-,C,(i:"ht'LE ED)
<br /> Complete all items in tris section,undess all it ins arc he same as SEC°"OON 1,If the same,write SAME AS SITE across this section, Ile ware
<br /> to check PROPERTY OW'.\'i%RSII"P"I'Ylaif boa.
<br /> 111.'I'A9NIv,OWN ER iNLr('iRNIA'IUN&,,ADDR .SS( ,t:S"F F3?s fIC3SaPLk"IFS)
<br /> Csrz„Plc.eca3l'itc;rr,s in this section,unlcz3s av acms are the aarsar as SECTION 1,ff thesame,v,ratt. s,YMt AS SITE”a>~,c.,.,t,a< ,n:ei<>ta, are
<br /> tochc&TA`NKC;3W`QEI<,.`STYI"ebox.
<br /> .1i `I ION 2),t<A1,11:01 NIL lti'A, 1'tI A sI)'SAI„t E'(,'O!)E,)
<br /> B, ,u of 1,X".w ra< E.E .`FC)1.)�'STS!er gel fee s�oura numlwr t,. _ . d KxSc _your i°, q:,J
<br /> V,ah t1.0, ),s wd,, inane i r,,.rein v a`.l r etvr a nuarteaiy srerag 5.,.rr[ta,ra a..�pc? ar tnW"o t,)C.Cr>= ;I>'? e
<br /> rE'
<br /> rc,thv I30F at 0. , v�a._.� .r,."; �3> d tai ITa lsa,atzc,ra;t uc�s'I°x_„Di Isio ,1"0,13.ra
<br /> V, l'ii","1L(}=.l.li,%I1,=s. l•I `4°sC._Ai'lbl?s/Ci`'iiit3$ i-11, %�I':SI1§I;CO.A,aFh1.1.'.1)1L9III'i1td'),[�I`.T_
<br /> OF-111!,.,�3,C.l iAP I`EN 1„Crit li i31 NIA
<br /> , and/or
<br /> C:(;31 .Cis lClefr>;la "l'TC S,j
<br /> ld .a.y >, sr. �t=.gid, , c.. 11—c z:r,ur ars;,ar ap moor,in mc5�Isng the Federal nd a x:.u., ?
<br /> any Nderal or taC€agency s J as non-p to'aMc UST:are exta.rlst fro:r Eh s roqtnnernent, € _
<br /> Chock OM",BOX fog fhs,,a 3 s. s t ilia,v.it',e us-e,!for BOTH i_L:C.3AL AND IlTl.l.ING Nt t,; IC,.N,rt .t's,
<br /> TANK OWNER OR 111.1 Iii.kafl hm7 Ll't1:SE.0 J A","i Y' .SLL"3"i"SJt, AN—L)1,A IT 1 i"„1`0i,,M Ai INMCALi?
<br /> (a)(13)01 a f E=,I. .r C1!A111!:R 16,CALIFORNIA COMA C ODE Co=3 E(AU'LA 10Na,t
<br /> I:vSIRUC'tION I OR Ilii-l,t)C.YL A 1,N: FS
<br /> 11:e tcE:zn?.y an jurssuri teE;o n„seniors are predetermined and can be oasaarao by c hd:.g the RrF argil(1416',>22',-4'30'3, The:,.,_,,
<br /> assign d by the loc"aI .ncy;!it)"ever,;Yais nusnbermuo be numerical and can rwt ontam any a'a i,,al cb.� 1,0ce,,
<br /> the State Board to a hg.;the;rc t_ry nrrnt er,please leave it blank.
<br /> IT IS THE RESl'C)°4SiBILITY OFTHE LOCAL AGIENCY"ITIAT INSPECTS 'I"ll.s FACILIT'Y 'ro yl,'RIFY TFIF, A(,'t_,f.P,\,(` OF THE,
<br /> LNFORxIA I'I{)N. i`IIIS A11111-1CATIO,"ytxC^A�1:NOT BE PROCESSED IF THE BOE',ACCOUNT I �t34'°.i3t:d IS 1OT I IL.I.M)I- THE LOCAL
<br /> AGENCY IS R SI't.7`�SIBLE FOR 'I HE CONUIL.LTIOI, OF THE "LOCAL AGENCY USE: ONLY” ENFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM "A"AND ASSOCIATED FORM"41"(s)TOTHE FOLLOWING ADDRESS, THE LOCAL.AGENCY SHOULD
<br /> RE AIN T111"s C>RIGI AUS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY Tlafi TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE A'I I:Y4 AT L R RESOURCES CONTROL BOARD
<br /> C/10 S W11"F..P.s.
<br /> DATA IyR,C3CES SING CENTER .
<br /> P.0) BOX 527
<br /> PARAMOUNT,CrA.911723
<br /> 3;93 FOR012ORI
<br />
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