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<br /> INSTRUAONS FOR COMPLE' 'TING F' "A"
<br /> GENERAL INSTRUCTIONS:
<br /> S1,,C'I]ON 2711 OF TI`I`LP,23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS ANIS SECTIONS 25286,25257,AND 25259 OF C14AP"TLR
<br /> 6.7,DIVISION 20,CALIFORNIA 11LALTII ANIS SAFETY CODE I2FQuin,OWNERS TO APPLY FOR AN UST OPE',ltr'TING PERK.II`T',
<br /> I, One F'<)ICM"A"shall be completed for all N EW PEI2WT CIINNGES or any FACTL aYISITE INFORMATION CHANGES.
<br /> `', SUIBMIT ONLY ONF(l)FORM"la"for a Facility/She,regardless of the number of tanks located at the site.
<br /> 3, This foram should be completed by either the PF'.R.34FF AP111 LC'ANT or the LOCAL AGENCY U IDFRGROUND TANK INSPECTOR.
<br /> 4. l''lease type or Pratt clearly all reTuc ccd information.
<br /> 5, Use a hard point,writing instrument,yota are making 3 copies.
<br /> 6, Tank owner muvt sobrnit a facility plot plan to the local agency as part of the application showing the lecaiio n of the U 'Ts vikh respect to
<br /> buildings AndN ark,f[S'c6on
<br /> � 11(a)(g)>CnCRI.
<br /> 7, Tank ovinernsdoent tiosicom Fliance wih state financial resnsibiliE re uirenadrds taihe local agency
<br /> as part of the
<br /> 7pQ Ix,tolent USTS
<br /> jsaciion
<br /> )(l i),C .l,.
<br /> TOPOF FORM:",NIARK ONLY C};vE I`l t'A`
<br /> Mark an(X)-in'l to box next to the hent th mhast describes the reason the form is Ewing completed,
<br /> h FACII,:i'I'Y/SITE lNFORMA`I'I£3N&AUT?F2.ii:?;IS(MUST BF.CO-NIPLETF,D)
<br /> 1. Recarci mane and add cc c(physical loc>a€ion)of the underground tank(s). •z
<br /> NOTE: Addfcss MUST have a valid physical ovation including city,state,and zip code.
<br /> P,O,BO zINUs,,II ERS Altt:.lC)"t' :C..CIsP`IAt3E:Ia.
<br /> Include riearest cross street and parme of the operator.
<br /> 2. Phone number must have an area code., If the taight number is the saute,write"SAME"in proper location.
<br /> 3. Check the appropriate bczx for TYf L OF BUS INF'S5 OWN'ERSIIIF(ex.CORPORATION,INDIVIDUAL,etc.),
<br /> 4 Check the appropriate l:xr for TYPE OF BUSINESS.
<br /> S, If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked 'YES".
<br /> 6. Indicate,the NUMBER,of TANKS at bhis`;1"I`Fi.
<br /> ,
<br /> 7, Record the,E,RA.11)#or w,;,,c„NONIF"in tile.bare prvvidcd,
<br /> Il. Pllt)l'E'R `s'()WNFIlw IN OR'v1ATION&.yF?DIZESS(NIUS`I`1311 C'OMPLEJ'F,bC "
<br /> Complete aII items in this scctioci,ualcss all ziems are the same as SECTION ION 1;If the sarne,write"SAME'AS SITE,"acrss,this section.,Be,, sure
<br /> to check PROPERTY OWN F Sa IIPTYPE box.
<br /> 11.TANK OWNER INFORMATION ION&ADI:)RESS
<br /> Complete all'tteints in this s,ciion,iaalt'ss all itcu s are the same as S'EC TION I,If the saarie,write"S y_sIF AS Sz 11;`across this-sectiou, Be scar
<br /> ro ch„ck AN OWiw ERS 1 Yt'I;box.
<br /> IV,13()ARD OF EQUALIZATION ION:S`I`S'i 0l%' (A z l,,.' C.C.(:lUNT`NC;�-1I3_l?(M ST BE CO,\11't�1`I"1!,IF.SI.(:.1IZ'1'dC"I.Ii 7,c ll;�i?l i>c i,"I5,
<br /> Di"VISIN)N 20 C"1I It(i1Z;t z 1 Id1_AI l II XND SA11 1 Y C ODI,;)Y._
<br /> Emex your I3ox e.<.f]ic ia.+ltx,ar,on(ROE)US 1 stor,)ge fee account nun be,w d=l bi es.,.hired tx,fore your I+nn"4 applic.alion can bc,proces xvi,
<br /> 1Zc t.at;cari ew iih tra(l liC>1,vii l t statism 9,hst}'axG teill recc vc a quartedy s o aa,e 100 rc.airu u,rcperhing,the at?.i,)U0(':rriiil p.r z,zrllon fee,doe,\o the
<br /> in yatar Us'Is, ",;rc 110!x,nv 1 Qode pctsons'exctrdltfrom paying,she stor.,l;c fee$o lt:uirns ill tint e x<cnit_ If you do not
<br /> ntat2swr of 1 alzc v
<br /> have,all aitc0ilm, ,u,<b l wwh t'.,;; ll0l',;,a i'. Nou have'any tFur-stions rcg artlinc the,Oce or tzxt.,r ptic:a,IrJr.,awt'cull tlz„ti£�l„.t l)10-322 00 0 or write
<br /> r
<br /> to.t=,,�001"al t,., f olloiw ,_Fa i3t,ar7 of Iic:ivalir atidsni Fc_1 Taxes Division,P.O.2oxCA S)�
<br /> V, 11F.17 (A-1_ 1',lL'S, lI`A ClAl.
<br /> 0111111`23,CNAP'EFa16,CAIJ ,:'Nj.yt:C)17 ` 1It,�Cr'�I_,ytA{?NS.d
<br /> I=Ic°r tl.c r � '.kdxis}r n i :,h� F, e,2;;t s tion ope 3 attar,;r s i n the I cdeml and tatlcpon,ibdii,, T_r>�c
<br /> any S exert"t fiorn dxr
<br /> Vt.l.$'C a1,1, at)3 It�iE.,.y Tif)l l is lx>i,I=, (i DDRESS
<br /> t4h c k w7VE fit X for the dial,will i,c,uwd r0r BO I'll 11GAL AND WILING NC)II,I£Ari"lONS,
<br /> €A'..,'K()ia,NER C)IR Mt ST SIGN AND I)A I'I "I`lll;la£ RNR AS ININICAF I D, l 3 t 1 it',NS 2711
<br /> T:NS`FILIiC""iI£T�1t£yfx ?1,.?LC3( .y .:�t�L�£`IE5
<br /> The c,o.ttnly a,.ai;ri,,dict.on ni-nbl,rs ars;etc j t_irtzuaed and ca n be obtained try calling the States Board t916)22 7 ti, 3 he.awil.y ni,j,lit t,rr,ay 4*u
<br /> assignud by tat lora at t,u,'ho%i v r,this minter must.be nurnericial anad cannot,"main any alphab: ical ch Ora tris, if zr,;,live al gal cre,,y pax.f,ra
<br /> the State liomal to assit,a xh?e fac:Miiy cLnr`hcT',Iv ase leave it blank,
<br /> I"l'IS t)I1i ItI:SIIONSIBILITY 01 `I llf, LOCAL 1GFNC"`r THAT INSPECTS THE FACILITY TO VERIFY THE I
<br /> Af Cr i2.ACY 6F THE
<br /> I�NI°tJWrIA TION, fkilS APPI-ICATION CANNOT F'Fi PROC E'SSI D IF' HE,'',BOE ACCOUNT NU.,1I3FR IS NOT FILLED IK "l HI,I,C bC AL
<br /> 1,NC`Y IS RESI'ONSIfCLE FOP I}Ii-, COMPLETION OF THE LOCAL AGENCY USE,ONLY" INF OR.1IA ION BOX AND FOR
<br /> F'C7I�WAtli.)IN(,;{.NI-'h O'k2.1"A Al`aI)ASSOCIA'ILI)FOR,Nt"I3°(s)TCI TIIE I O1,LOWLNjG AI)IDR SS. THE LOC AL.AC%ENC SHOULD
<br /> FZETAli;Tllli<}RIGINALa`' AND F'OR ARD THE YELLOW COPILS TO THE FOLLOW lIN,+,G ADDRFSS.'1111-PINK COPY Sf'aC)l)m BF
<br /> RIf I AI'4I D I3Y T l}?'I`AN O WNIsIt.
<br /> STATE Al E 01 CALIFORNIA
<br /> S Ela VvATLRRESOURCES CONTROL BOARD
<br /> C/O SW
<br /> DATA PROC ESS]INCl CENTER
<br /> P,O,BOX 521
<br /> PARAMOUNT,CA 90723
<br /> 393 FOROIkIll
<br />
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