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�. � � r et rr
<br /> N IS I COMPLETING
<br /> 0.$I.Nr.:RAt 8;4.."9TL'a.4 CZIl.fi'S,
<br /> SEC"I ION'2"711 of T i I I,I;2:3,C[1.'i.rTEIR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 2528 ,2528'7;ANI)2..5289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA IIEALI`11 AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPI RATtINC3 PLRMIT.
<br /> 1, One FORM"A"shall be completed for all N EW PERMITCHANGES or any FAC:SLIT ISI` F INFORMATION CHANGES.
<br /> ". SUBI 11T'ONLY ONCE(1)1°'OElvt"A"for a Ftaci ii,y/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by either tete PERMIT APPLICANT€r the LOCAL AGENCY UND13ROROUaND TANK INSPECTOR
<br /> 4. 11case type or print clearly all requested inotxnation,
<br /> 5. Use a hard point writing imiru hent,you are making 3 copies.
<br /> 6, Tank owner roust submit a facility plot plan to the local..agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),C;CRJ,
<br /> T Tank owner must submit documentation showing compliance with state financial responsibility requirements to the Local agency as pan of the
<br /> application for petroleum UST's[Section 2711 (a)(}1),CC'>RJ,
<br /> TOP OF FORM:"MARK ONLY ONE'.t'['I:W
<br /> Mark an(X)in the box next to the iters that bast describes the reason the form is being completed,
<br /> I FACILITY/SITE I`alY1R11A"1'ION&ADDRESS(MUS BE C E.),VIPLE"t`-M)
<br /> 1. Record nature and address(physical kxcation)of the underground tank(s).
<br /> NOTE: Address MUST have€a'valid rhysrcal to ce6ort including city,state,and rip code. _
<br /> IW. BOX NC.I4IBE3'RS ARE,NOT AC.0 Ei'rABL,E.
<br /> Include nearest crass street and narre of the operator,
<br /> 2. phone number rtstrst have in area code- If;�he rti ht numb r is the same,write"SAME"in proper location,
<br /> 3. Check the appropriate Iva,for TYPH,OF BUSINESS OWNERSHIP(ex.CC312,1'ORATION,1NDI'Vtl)U t L,"etc.).
<br /> 4. Check the appropriate box forTYPE,YPE,OF B SINESS.
<br /> 5. If Facility/site is located within an Indiana rescrvaation or lather Indian trust Iandsi check the box marked"YE',S".
<br /> 6. Indicate theNU'�'BER oaf TANKS at this SITE,
<br /> 7. Record the.S'°:.I',�t I13 or wrne"NONE"in the space provided.
<br /> II. PROPIi-'RI'Y C)WNEta l\bl,()R.MA'FtO t,�,,AI)1)1 l SS(M3 17S-I'll[r CO I'1,E rFDI
<br /> Complete all items in this suction,un!C S all itcr.ts are the same as SECTION I;If the s unc,write"SAME AS SHIT:"across this section. die sure
<br /> to check I ROPFRTYO I ERS1111'"I"YPH box,
<br /> TIT.TANK OW'N R UN1tORNIATION&AI)DRFSS(NI.JST Ili:COMPLETED)
<br /> Co-mplew all ttcrns in this section,urt]ess'all ite rns are the Sallie as:sliC TItJ".'o I If the same,write``s:i 4I1 .AS Sz z ii'"vtcr<>ss blit soot€cart. Be:•arra
<br /> to check,TANK OWN;tvRvTYPI -40lx.
<br /> IV,BOARD D C)Ia'EQ'.1-A1.7,AT IO CIS f S.,ORAGF1 PCI"AC.C.a,)Ci°^T N IB .R(MUSTBE COMPLETEDI SET M 1'':C_°t:,,o,
<br /> DIVISION 20,CALIFORNIA H1,1ALT11 AND SAITTy COD1,L)
<br /> I3€tt r vom 301,ard,)f halt,,ii .:a..,.t(BOE')US1,stet aas;c teeaccount xauTntvr xhich as,rc.luircd b:for you,Ix mlil gal;;watiu..-01 to.;ro e,��c:d
<br /> Regi,tf ation 9e.;h the BOO" d$:. a.�tsar you vvcll raccive<a quarterly,vtma;e:tee ren.-n in rep€9ning the 9t3;at(>{6r3;'s, , :,}>-_ wt<,,,u a il_.e oathe
<br /> t.w i er of art.your a S l's. `I It, Ca es t cede persotts.exc,rsSat frvaa p.ayit g tYtc strasial t f sa.=.�t ?"trrs
<br /> have,all account nuirb"r x6th 0w Is()C or if you have any questions regarding the Ice orexcmpdon ,pleasocatl,hc lata.,a, i:ri 3'L 96 0) a. srr.,c
<br /> to t t„LWE at Ole,f ifao inll adclrcis ifo,od of{dual€taxtio€t,Fucl'faxes Division,I1.0Box 94209,Sacramcnlo,f"A 91„,7. .
<br /> V. Ph:"I'ECOLEUNll U'S f I•INr'tN IAL itl."1'ONS1B1l lTY(NIU-ST III:4:f)„iIl LE-1`ET)lri)1t l;Z z€.'>' 1, ,;SEE .,C;: fr 27
<br /> CJI' FFIL}21,CHAP ll:rt 1.6,C„AI.II OIRNiA CODE OF PEGIJI_A"I IONS.)
<br /> h c.E€f vv the nu,.T.fx.�') l cd by tl.c.owner anJ/or ,apc.mu)r,.n a,tc:6118 the Fedreral and State financial tc,,polas€I,t(.ty by :
<br /> art° 3 cd:creal oa S131c aS;mcy as wclla111on pQlloaeuln L 4"I`s at,-exempt bolo this s iart.cr, r.t.
<br /> VI,LIi£IAI.:vOPFIC�ATIE.7Y AND BILLING ADDRESS
<br /> Check ONE-iv?:C iol t.._1�ddnc, lh,! k J; u„cd for W)I'll LHG',AL AND iSiLt.I t.E N it`ll CAI IONS:
<br /> TANK OWNER OR AE,i r[C3II,Zt..l.)R” ' I.SEN tAI'IVE MUST SIGN ANI:)11A'LE"l"Ill;e1C)ICG1 A l.`;l)"{.,, i.:1;,. , , a;s.,. n , iS' ,'I1
<br /> (a)(13)OF T11 L l,"23 ClIA111"ER IC,CA>.ir 011,N-A CODE OF 1ZEGU1�'l11ONi,l
<br /> _1NS'i'RUC17C)N FOR 111 FOC:1L/tGENCIES
<br /> 13tt^ raatrnb:rs arc pr..atete,rntraett and can be oE,rtatnctl by calling this State;Board(9161r'.a, :3t}1 I lnc rau.;tisc r.,a<ts',c
<br /> assigned bythc.loc:al atg cncy;how vet,tilts number must be nurnedcal and cannot contain any alphabetical characters, If the local agencypr„h;rs'
<br /> the State Bo.atd to assign the facility number,please leave it blarrk.
<br /> IT is THE`'RESPONSIBILITY OF°i`HL LOCAL AGENCY Y °lHAT INSPECTS "4HE FACILITY '10 VERIFY THE AC,:C1,'TRAC Y ()I^ Tiff
<br /> INFOItyt'/0,10N, TI HS APPLICAT ION CANNOT BE PROCESSED IF TATs BOB ACCOUNT NUMBER IS NOT FILLED IN. '111l i LOCAL
<br /> AGF1'tiCY l.S RESPONSIBLE FOR "I'i;E CO,'01'I.ET`ION OFTHEAGENCY"LOCAL USE ONLY” I`tErt�RIVIAT'ION BOX AND FOR
<br /> 1'C)]CWAILi:)`ING ONE FORM"A"AND ASSOCIATED T'C)ECM"B"(s)T"C THE I''C:3I..LOWII\C ADDRESS, THE LOCAL J",CaE C:`t`SHOULD
<br /> IdEITAIN'I HE ORICsU"SAI.S AND I'(IRWARD TIIEIs YELLOW COMES TO I'IIE FOLLOWING ADDRESS,THE PINK COPY SIJOUI_I)111'
<br /> STATE OF C',AI".IF'ORNIA
<br /> STATE areTE WAIT R RESOURCES CONTROL BOARI?
<br /> C/0& .E.1,P,S.
<br /> DATA PROCES LNC CENTER
<br /> 1',C),BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3193 FOR012DRI
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