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INSTRUCITONS FOR(X)MPIEIINORM'A'
<br /> GFNFRAL IN.SFRUiCTIOWS-
<br /> I
<br /> I. One FORM"A"shalt be completed for all NEW PfiRmns,PERWI'0JAN(;JIS or any FAC31,171"i/SlI '
<br /> INIURIANFION CHANGES.
<br /> 1 SUBMYr ONLY ONE (1)rX)RM'A"for a Facility/Site, regardless of the number of tank-, located at fhesit
<br /> 3. This form should be completed by either the PERMIT APPIJCAWothe LOC' LAGENC'y
<br /> INSPEA-FOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies,
<br /> TOP OF FORM.- 'MARK ONLY ONE TIMM
<br /> 1. Mark an (X) in the box rest to the item that best describes the reason the form is lacing completed.
<br /> L FAC-1111-Y/S17111 INFORMN11ON&ADI)RI.,;&i(mmr BE a)Mpurnm)
<br /> 1. Record name and address(physical location)of the underground'tank(s).
<br /> NOTE: Address NIUI�Thave a valid physical location including city,state,and:rip code,
<br /> PO.BOX NUM4111R,ARE NOT ACQTrAHI-,E-
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area cride, if the night number is the same,write"SANIJ."' in prope.t,
<br /> 3. Check the appropriate box for TYPF' OF BUSINESS OWNFRSHIP (ex, CORPORATION, YNDIVM
<br /> 4. Check the appropriate box for TYPE OF BUSINF-S.&
<br /> 5. If lacility/Site is located on land within an indian reservalion of olio inifem trust lands,check the boK
<br /> G. Indicate the NUMBER-of`PANKS at this SITE.
<br /> 7. Record the ETA, 11) # or write'NONT., in the,space: provided
<br /> 11. PROPERTY OWNER INFORMA110N&ADDRF.RS(MIJSI'131-1,CoMPLIrlin)
<br /> I., Complete all items in this section, uniesj jilt ncits are the smm-Pty-SECTITON 1;of the samt write 'S MIA,AS MT.'acro±!s
<br /> this section. Be sure to check PROPERIN OWNF�RSIBP'J'4`IT'l box.
<br /> III.TANK.OWNHR INITC)IRNINF[ON&ADDRF&S(MUST'BF
<br /> 1. Complete all :terms in thi:,section, unless all items are the Sterne as SIS{ 110N 1; If the same,write 'SAME AS -UM'
<br /> across this section. Be wire to check TANK OWNERS1111"ITIT"box.
<br /> "FORAGE?YHE ACCOUNI'NUMBER(MUSIAM, C I , Tn,))
<br /> '(4m il la
<br /> IV BOAPD OF EOUA'k��/,IVJIION USI'S
<br /> Ftl?,,jof Folualizalion MOi,) !'ST storage fee 3ourt jld)cr whic"11 is, roquir-41 4. ;tore: yom ci(7 4t Ca
<br /> Ne prfynu,�sed, with the TIOl-,will ensues that yoo will rec�,rx a qji,irtefly 31,orapl- fe'e, r"lum i•
<br /> tht, of - ll-n� placc(� ir, wr`j,,S-Is, 'I'lic 110l� will C,vk� per�-,Ons �-v the
<br /> r`- 1��Olon X
<br /> )of 0c nv h1vC j.c! n,,U- ,,r suites the 1101 of if ✓ou f—j:
<br /> io ,5Q� , cine
<br /> In the Titus`s,jt 111� fi,!4w-in,,
<br /> t
<br /> V. 117.CAL MY111FICATIONANT) 3IIJ,INGAlit'1RI',,SS
<br /> 1, (:heck- ONE BOX for I he auldress that wifl be used for IXYIII IT jGAI,ANT.)BIIJTN(;NO`11F[(AJ'ToN,&
<br /> APP1A(AM.I'MUS`F,SK;N AND DA711j'11111 1°0t PA AS 1NDI(WIlu),
<br /> INSHM(MON FORTIM 1,0CALM-AiNCIRS
<br /> Thc county ans, jurisdi.,ion rnnib,--s are predctern;inkd and c<,n)w obtained by calling the State Board (916)"139-24f1, The
<br /> Giciiny number r1ay be assig-ric, by the lo"'a; 1gCncy; h(,,',eVCn" this number must be numerical and cannot contain an If
<br /> the]oval agency prefers the State Board ;o assign the facility number,please leave it Vlar&
<br /> I'r IS°311E RESPONSIBILM 01711111 IX)CAL AGI-INCY'IT LNr INSPECTS11112 FACTLMYTO VERIFY'ITIS
<br /> AC: . RACY OF 11I1?I2NFORMA110M 7111S APKICNI'YON CANNO`I'I1E PROCII&q,"D IF'ITIR BOP AC(X)IJNI'
<br /> NU IH IS NOT 141J,I-;D IN. '11111 YAW-AL A6;<NCY IS RESN)NSIBM RM 1`11F,COMPI-IMON OF THE'LOCAL
<br /> AGENCY ITS11 ONLY'INIX"RMNIION DOX AND FOR FORWARDING ONE FORM'A*AND ASSOCIA'I'M FORM
<br /> "Ir(syfo-nIE FOIT-OWIN(i ADDRENS.
<br /> SFIVM 01"CAIJMRNIA
<br /> 'TI`/VI`E WiVPER RESOURCHS(7ONFROL 130ARD
<br /> C/o S.W.F,KP.S.
<br /> DA`I.'A PR(X1.1-13SING CINI'M
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br />
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