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INSTRUCTIONS FOR. COMPLETING
<br /> "All
<br /> SEC:T'1C).`v 2 i l )I""1.l 1`t}:>23,C..Ia:AP-11IR 16,CALIFORNIA CODE OF RE.GULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION'20,,CALIFORNIA Ill AL`t'13,AND SAFdTrTY CODE REQUIRE OWNERS'I"C3:APPLY FOR AN LST C)FsI RA'I`ING I'IiR IIT.
<br /> L On'a l't9RM"A"shall be c omplewd for all NEW PERMIT CHANGES or any FACIL 1SFFFI INFORMATION CH ANNE&
<br /> 2. S13BMI1'OINLY ONE(1)I OR. "A"for a F aci.lityl5i?u,regardless of the rtearrtber of tanks located at the site.
<br /> 3. This form should be completed by either the Pf R.4IIT ATIP11CANT or the LOCAL AGENCY TJPID1:I2Cekf3UND TANK INSPECTOR.
<br /> 4. Please type or priest clearly all requested information.
<br /> 5. Use a hard point writing instrurnent,you are.making 3 copies,
<br /> 6. "Tank owneromust submit.a facility plot plait to the local agency as pati-of tht application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCRJi
<br /> 7, Tank owner must submit docurrtentation showing compliance with state financial responsibility gttirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(11),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> :Nark an(X)iat the box next to the item that best describes the reason the form is being completed
<br /> L FACII:ITYlSITE,[INFORMATION&ADDRESS Q.."luS T BE COMPLETED)
<br /> I:Record name rand addtecs(physical location)of the underground tank(s).
<br /> NOTE: zAddsesx MUST.have a valid physical loc alion including city=,state,and zip code.
<br /> RO, BOX NT.;NIBE'1 S Aldi;IS6'a `tC.,CEJYI' ALF,
<br /> Include nearest cross strut and name of dhe operator.
<br /> .,. Plztrn,,,non.,cxm,nnkaaaeataarea ct,cl�;- =1 gut o1;in.,,,.l;etisthe sa�sss,write°'4,tM?;"itprolrer3dcstnut.
<br /> 3. Check the al pwpriate lxsx for TYPHI Ol'BUrSEN SS OW.N,RSI IP(ex.C;O12I'CIb,1'I"ION,INDIVIDUAL,etc,),
<br /> 4. Check the appropriate box fcsr TYPIi 01x t3C.SINESS.
<br /> 5, If Facility/Site is lases+ded within an Indian reservation or other Tndiacn trust lands,check the box marked`YES",
<br /> 6. Indicate the ItiL;4'IBER of TANKS at this SITE?
<br /> 7..Record the 13,P,A,I.D#or write"NONE"in thu spaces provided.
<br /> IT. ITC PIS,Z'1'`r'f}'rt i\;Iiii NI-'O :MA,riON&ri)a)IZl,SS('US'f lI' C'.(}MF'LE T'ED)
<br /> Complete;all items in this Rcction,unless all itctrts are the same as S1 Cl1ON 1,If the carne,write"S ANSI:AS SITE"across this wctien. Resure
<br /> to check PROP OWNERS IIIP TYPi:box.
<br /> III.T:A�'iC C}A4'g'IIZ I:4I=C)ta�4a't'1"IC);ti��Al)I}i�l,tt(i'1t:�'S I"F3F?C:t:»ll'I.II'`Lil7}
<br /> Complete to all itc.rns in this section,unless all ite int are.the:same as SEC II"It7N I;,Ifthe same,write"SAME AS SITF`,aac rbcs tl;is seotiort, rle s re
<br /> t ch t.:k'I A Is C)1 NERS TYPI ha A,
<br /> IV,BOAM)OF EI€:?UALIZA-ITC?� -;S'?S I01i AGE'FM ACCOU �'1C;St T§E C::t}l'11'1.I:"I'I.I7.s t:l:'t Til ta'1.>. ,t..I?:SCY EI,' l ,
<br /> DIVISION 20, Aiv1"D SA F"I Y COl"ni,)
<br /> Entcr Yom Hoard of I: It ali"-Ition(1101"),L; l storage iee aecoura number xhic't is wipaired before your pi nii al plic i .,.,-: €K��a,,,c c^swd,
<br /> Td gin uationisillilhc B011i'will circ
<br /> ..ec t.a you will receive a cluartc;rly astorats feu scaiarrtart sepraitirtg the;9i}:rY>!€.v,;il >n'.i:e c3a.e on,:,ac
<br /> nurnb(cr of It,+aljon. zi,ae cd in your t bed's. `111c B01—will code lxsrsons exempt from payiar,�the stor:q Q fec,io twi,.a.r„'�� ,1 no, if eves ch>its
<br /> heave,ant acciOunt n.umbcr with tlw BOE car if you have any questions tegardlne,the fcc or e.xcinplisns,ple..aw("Al,;av 1'Ie r..a 916 122 9,>69 or txr-i,
<br /> tins tltc;130E nt the fotivtt mg addl,is I3t,od sof Equalization,Fuet` axes Division,11.0,Box 942879,Seac,<i a^v at<),(,”A 91,279
<br /> V. lsl:`l'ItC}4,liCtA 1,s l'I[\it ti€`,l/if lZl�y1'E;;)iNSIT II.ITY(,NWS`] BE C:(}41PLI TED FOR 1'hIROT ,`,.,'l l.STI` (7:a1,1',,'iFIH SFC.: (t 2`11
<br /> OT''l"I'l h1�23,C.1trA!'I'LzR 16,CALIFORNIA CODE 01 h'EC .'1-AT^IONS.)
<br /> blur t c tsy ,u r_u tier«<„+cr opc.mtor,in and Stale.financial€c.�„rts,is+t. > ,c�p ,,,.. .,,a.i S.s e,=. by
<br /> any a cdc rid Lai State"e,ag,c,ncy as uell as Leona p ,roie.u.n UST,',at,,,,cxewtjtt fron.this zwjujacmcnf,
<br /> V1.LEGAL N`O T`IF IC ATION AND BILLING.Al l?adzSt
<br /> Cltect 0"1v,! BOX fix the th t I"ili be ur cd for I30111 LEGAL AND BILLING NOJ Il"ICA IONS.
<br /> TANK C}4vNER OR AT;'I°11OSIZ1;13I},AIE I'IIl)1 ORN1 AS INI)IC 1,.;), z sIT' i„ IT I,"S 711
<br /> i.(l3)4)I''h1 a L1,23"C"I1.Al''fhh 16,CALIFORNIA CODE OF? GULA I'I 3NS.j
<br /> IlS"T`1�L1C"11f.3�h(Jid I111:1�f3C:A1..�A{3.�`vCizvS
<br /> The,t a¢ at;°an t=aa',=i t.<ra3 (J c
<br /> atMs;tl'x.. .a.c r:r,r< res nisa�,bf a.cl can be t,taan<i k y� aalFiral tEacsS€<ttE,;ealr I £si'227 t
<br /> 303, f r� y
<br /> as,�igncd l;y the,lc,al eta slcy;hc3 .s r,thig manbe r rnuse be n mciical and cannot contain any<alph abcdc:al cbarac..cs, 3.<l,w 1 ,, ' i,cnu p.4
<br /> the State;I3caatca t.,a,,crgtr€sir face fty nuniber,please leave it blank, _
<br /> IT IS'11R," RESF'1)NS[BILITY OF °1'[1113 LOCAL AGENCY THAT INSPECTS TIIEs" FACILITY '10 VERIFY"HE:ACCURACY C}I< '1 I13
<br /> Iti}ORMAI ON} THIS APPLICATION C.;,A:"1"°v"OT BE PROCESSED IF TRE BOB AC:C;C}UNT it]NIBE11 IS NOT F111,1l?IN: `1`HE LOCAL
<br /> rAG1iN'C:Y S IdlaS1'Z)? illf,l FOR "(Tari CCiA2PLF,T'10N O `T'}IE "LOCAL AGENCY USE ONLY" Iii l'OR s'tATTOIN BOX AND FOR
<br /> T`a{)IZW.1RDINt"i ONE FORM"A"AND ASSOCIATED FORM"I3"(s)'TO THE FC:FI..LC}4x1ING x'#TyS)1tESS, `['III!LOCAL AGENCY SHOULD
<br /> REI lA'N^1111.;ORIC 1N ALS A-ND FORWARDTHE YELLOW COPIES TO [IIF FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> R 'T"AI°vED BY]HE TANK C)AY°'SE
<br /> STATE OF C:AI.IFORITNIA
<br /> STATE WAIT,R RESOURCES CONTROL BOARD
<br /> CIG S 4v.I..E,P,S.
<br /> NG CEN 'R
<br /> DATA PROCESSIl TE
<br /> P,O.BOX 527
<br /> PARAMOUNT,CA 90723, u
<br /> FOR012ORI
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