|
0 0
<br /> INSTRUCTIONS FOR COMPLETING FORM "Alt
<br /> GENERAL iNSTRUCTIONS:
<br /> EC;`T ION 2711 t,)T•'TI LF=2:3,C1 iAI'"lFR 16,CALIFORNIA CODE(7F REGULATIONS IC3NS ANI?SEC;'ZIONS 252$6„25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIF()RNIA I1PAUI`Ii AND SAFETY£:C1DE REQUIRE OWNERS TO APPLY FOR AN U-ST ON,"RAII;NCs PERMIT.
<br /> L One ltt'9RM„A`.shall be completed for all NEW PERM T CHANGES or any FACILFI YfSITE INFORMATION'CHANG .S,
<br /> 2. SUB
<br /> MIT ONLY ONE(!)I'CiRM"A"for a Facility/Sitz,regardless of the number of tanks located at the site.
<br /> 3. This form should be coropletcd by either the F'ER11,11T APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPfiC.`TOR.
<br /> 4. Please type or printclearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6, Tank owner must submit a facility plat plan to the local agency as para of the application showing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711 (a)(8),CC RI.
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as Part of the
<br /> application for petroleum US"T'`s(Section 2711(a)(11),CCR].
<br /> TOP OF FORM:"MARK ONLY ONF*,IT:T'
<br /> .lark an(X)in the box next to the item that:le ,t describes the reason theformis being completed.
<br /> L FACILITY/SITU.'.!N'F RMAIION&ADDRESS(MUSI BE Cf".C)V1rRI.ETED)
<br /> L Record narrae_nd addm s(obysi ld location)of the underground tank(s).
<br /> NOTE. Ad b ss MUSTtrue€a valid phy,,c,ai loceion mcltiding city,state,and zip cock.
<br /> C).BOX 1°a'UNIBERS ARE tib)"1 ACCIEla'I'ABLE.
<br /> Include nearest,cross street and mane of the operator,
<br /> 2. Phone number must have ut area code. If thea fight number is the sante,write"SAME"E"in proper location,
<br /> 3. Chick the appropriate box forTYPE,PE,OF l3LSZNI:SS OWNERSHIP(ex,CC3Rl'ORAUON,INDIVIDUAL,etc.).
<br /> 4. Check the a6ropriate box for TYPE OF BUSINESS.
<br /> 5. If Fac'ality;Site is located within an Indian resene atfon or other Indian trust lands,check the boy.marked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the I:-RA,.ILD#car write ACINI."in the space provided.
<br /> IS. PIZOPF'RT'Y OWNER INFORMATION 3r ADDRESS(IUST L11,C:OMPLETFD)
<br /> Complete all item;:in this scc:tioo,unless all itcmr are the sante as S}i£"l ON 1.If the s=aint,wy-he."SAME,Ars SUE"across this section, Be tare
<br /> to check iSaZ£3§atsRTY OWNERS1 illi`l YPli l x:
<br /> TTI.TANK OWNER INFORNIA ION,,4 ADDRESS(MUST 131::COMPLETED)
<br /> £:tarn}sl,xd u11 ttt.r,as tri ylaa,sc;c41c>e;,uFL3easfi ail s€csns are the sairac as SEC"3`1t1,`'C 1;Tf['aa;same,wawa;o SAV11'r AS S111,—ac=Os.Hats section, Be sure
<br /> tt5"ii,wc.a'I"ANii f)W,\J.cZ;r> i°?T'U hex.
<br /> TV,tiClAiZI>OU EQUALLZATION t S T S l01z�ACtl,FEE1 AC.COU 1 Ni,l Bl.,'R(NOUS i BE C0]l ll`f,F,-Ifut.SET'ARTICI.,.5,t..H Al"11R,6.75
<br /> DIVISION 20,C,.1U OICN IA,13;'`A1,11I AND SAFETY I Y CODE,)
<br /> .,II.. .;a'll;'11011)L; T solage fcc accollrit nomber al i h i,rv(p,i,cd t�Com your(x ra, .>"1,.(a', !ion�.,_,1_,a roc c.,,cd �
<br /> heti i t na o n si c l -B01 e +' a s ,lc. �a W111 rc c ave a quarterly 4 s tag e f v n t.r a at r porti ty th 0 ,' ° { a i t x c' s ;
<br /> w ntal.r o'f;.il ns lit �si in your T T s. I he B01 sxa_3 cxxle Nrsons exempt floln;loanpis}ingi 1h.-,s,car::, fcc,i , t,a.... ?.,. .. if%,'u 3.a>a
<br /> iras�,a�,a�<:a,.a.2t t,arrat�.a s.it a she S3( Ii r a s°cu}aa,c.aaty;; est;c;ns r ac.la a tlar'il c car r s miUon, ;lcvs>,.,.+.1.,_o s;{ ,22 ""(,', %T_
<br /> to tho 1301l at thc(c>tic a inn a:fth<,. .3t,rd of i"'pualiaation,Fuel Taxes Division,11,0,li,ox 942K719, ,,.a ,,,.,, .CA
<br /> , 1111'-FROILI:La1l,°'l 11NAN `I_'tl.?ZFS110- IBTIATY(,V'lis`s"I fiE, 'o%lvL rF' et7h l';^` lC�?�.1.";f US' a,,`, '' '2'111'
<br /> OF`ST`:l.!.w ,C.llA':l,-K 16,CATIJI£.. NIA iOD ,,OF RE.GLULAT"IONS,)
<br /> Tdsr-talc t.ta ts,?_,, onaak.t a...l,tsz oj>.a,a.<?P,an ant.,t,rtg,'lho...daral and Stlae lt..<. vastl«.�s3ty i,a .ly lc",,: .,. .. a. L'S d t:y
<br /> allyri
<br /> T z dcr:.'.r r�,t.atfz at,,,r.�y as a,.13 a,ac>n pa?rs.ioa,ln L S'1's are txara:pt front,?ta.a t,..,,a.crraent.
<br /> VI.LI:Gt1i.NOTIl'd'ATI£.)." AND BILLING F'sDD'ESS
<br /> Check O\3,ifi;XJoi du-add= ss that sill be urcdfor 130111 T,F iAl,AND BIT.AN L£s'1iflCCa l,a)�' .
<br /> TANK OWNER OR At,11I0RIZ Ts REPRESENTATIVE,IVI.INS I'SIGN AND IIA 11.1111;I`OKNI AS JN111(,A l l..t). i ,t,3... _,la)"IS 2-1`11
<br /> (a)(13)OF"I 11`F,23(11AVI'T R 16,CALIFORNIA CODE OF RS'.GUI.A`T'IC NS]
<br /> INSTRh3C711C3NI°OR TIUiLOC:ALAGENC:IES
<br /> �.
<br /> I§ <,uA�Ly>an,lEa_,�sy?ecar.tato . .ar }s,. c,,.t�r ara3nir tat'aarredhycal s,d hutut<;t3oaar 2 ._ a`.. r¢s:Ea t F. ..y27,13
<br /> t>`
<br /> assigned by i,ac io %!,t3. ...�y;ho w-,c,r,th.s ra..,x'h r sr;ust be matrical avid cars us contain i,ts ,a€plt"t>,ncal,Izat ac.c n" if iTa.i I< ..t ag ncl Iax.._GtS
<br /> the Star'Lies,ld to assaE,sa the isauty num or,pleasc leave it blank.
<br /> It IS IETI, 1ZI.S1'tJi`ZSIBILI1'Y OF THE LOCAL AGENCY THATINSPECTS THE FACILITY 'SCS VERIFY TIlg ACC' RAC.,t OF ITTE
<br /> INF°OWN A`IONi THIS APPLICATION CANNOTIiia,PROCESSED IFTHE BOE,ACCO. UNT NLMME"1Z IS NOTFILLED i1,1.ED IN« THE LOCAL
<br /> AGENCY IS RESPONSIBLI FOR '1111F C`.UV1I'I.ETIC}N OF THE "LOCAL AGENCY USE ONLY" I`II ORN'TATIf3- I3OX AND FOR
<br /> FORWARDING ONE FOR-1"A"AN'3 ASSOC IA"I rD FOR °"B"(s)"T`O 1.11F,,t 011 OWL\C`s.1I}DlvI?:`aS. THE LOCAL AGE C SHOULD
<br /> RETAIN I'llfOIRK 1NAUS AN!)FORWARDTHE YELLOW COPIES TO HE'FOLLOWING ADDRESS. TIE PINK COPY SHOULD BE
<br /> S'S"AT"Su CISH CALIF'OR SIA
<br /> S l:A`E WATER RESOURCES S C"ON'P12OT.BOARD
<br /> Ce10 S"WJI.I"P,S.
<br /> E3:��li'r�?'I2RESSING CENTER
<br /> P,O BOX 527
<br /> PARAMOUNT,CA 90723
<br />
|