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<br />1Ns,rR*r10NS FOR COMPLErING Jak RM "A"
<br />SEC '1'ICT� 2711 iiI^ "['T'i`ll%: 23,
<br />CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND ITEC:-11ONS 25286, 25257, AND 2.5289 OF CHAPTER
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<br />6.7; DIVISION %0, €'ALI.FC)%NIA HLAI °T`II AND SAlryETY COTE EZ iQUIit OWNERS TO APPLY FOR AN US`F C)1'Ish.A`l NG I'k32e.NI1'T'.
<br />1. One a°'t)RM "A" shall be completed for all NEW PERIMIT CHANGES %S or any FAC:IL,I° VISITE I*,rFOR-1A`? GN CHANGES,
<br />2. Si.`=I MIT ONLY ONE (1) FCRM A" for a Facility/Sire, regardless of the number of tanks located at the lite.
<br />3. This form shoui,I N completed by ether tlae I"ERMIT APPLICANTor the LOCAL A(3ENC:Y UNDERGROUND TANK 11NSPH(,` T"T) ;,
<br />4, Pica5,e ty1 or grist cicady an r^qurotecl Infor ation<
<br />. Use a Irani poem a,r,Cang ,r, a,.anrent, you are rnaking 3 col ics,
<br />6. 1'anlc owner rr ` t s rl ixiir, a facility lot, plan to the local agency as laali of the application showing tkt z €areata of the USTS with re.s . t to
<br />buildings ;and l,_r ,.3a _IScctron 2711(a)(8), C'C°ISI,
<br />7. Tank owner in , slabber s3 ttax <cntaii n showing coutphance with stat., financial responsibility rrscltaar°.qn<rsata, no the local agency as Isrcrt of ,he
<br />application for per oleum LSTs (s,,aei=ate 2.71' (a)(I1), C:C:111,
<br />TOP OF it` RNI, ".tTARK ONLY ONE, I"C E A"
<br />Mark an (X) in the box next to the iwin that best describes the reason the form is being completed.
<br />I. FACILITY/SITE INFi)IIMA11ON & AI)1)la.Ls (MUST BE COMWLE17ED)
<br />I. Record narne and <ar3dfyc s (physical locaocm) of the underground tank(s).
<br />NOTE: Addrt st 1.Is, ST least,, a rel d physical ;,canon incIrnE rg city, suite', and clE ryale_
<br />P,C3.-BOX iVi;Ivaf3ERS ARE NOT ACCE"?1ABLE.
<br />Include ,r;arest c.ros5 streetanei narne of the olaertatoc,
<br />2, Phone number crust have; an area code. It: the alight: number is the same, carne "SAME" in lair per location,
<br />3. Check the appropri:ata Ixpx forTYPE OF l t,SINI' S OWNERSHIP (ex. C ORPORA°i ON, INDIVIDUAL, ctc: ),
<br />4. Check the apir,r€ praaic I.x)x for`fi YPE OF BUSINESS,
<br />5, if iacilityfSite is located within an Indian reservation or outer Indian trustla nds, check the box, marked YES".
<br />f. Indicate t u,, ,NU 'HU'R of "TANKS at this SITE.
<br />7, Record the ET.A,.If) A or vsda c `"NONE` its the, space Provided.
<br />IL PROPERTY Oth%INUN L'yFORMAJIGN & ADDRESS (t1US`I' ['3Is ClfihllST.L: Eli)
<br />Complete all oons in this sc.4�tion, t.,,?u:;s all t,tnns are the, sane ,as Sr C' IC. N 3, 11 the au_e, .slate 'S -NNE, aS Sl E', crEs_. 41sss sc dngr. Tse,: tam,
<br />to check PROPER TY OWN RST iP TYP hox.
<br />111, TANK ClWNll:13INEttIICMATia,J.` & AI)1)R-SS (y1i S"1 BE C 03,1I'I.C: 1 «;))
<br />t°ok?ahi,ae tall ttzun, in this �. € t.c=n, arnacsa all slests are the ware=t, as ST""CTION A, I: slec s,..,ae, r S! IT, a..,.,..t,>s s .a.,,,rrr. 1It, r3atty
<br />IV, BOARD 01 i"()A,,-AI ZATL)N Sl' S'I' O AGI- i`feli ,C"i.3UNF NL:e BER ('sUr'T<T RE CUMPL ,'>'iaa ,C:IIatM 6, /5,
<br />DIVISION 20, CA.,t4 ()RNl A iIIAAl-1 I AND °aAFI""Ty C OI)Is.)
<br />Enn.,,r yo air 1.3,m , < f l'q,,.,.arataon ([301s} UST (` Storage ice acc ouut ntrnal c ul ich i ,. ,� .a_ .i tc rc;r�° o ,- :rrr�s al I>ia��exta4 r, Can hr,
<br />the k c, . a.,:J etl.'sure dwt y >u xil reC ivc� a qu�aocdy
<br />r s ca as r;�: ,.,t.s,, s ha s.,., jai 1, a yalC t, ,uu .luc; on rtae
<br />r,nib .t of ¢,ul« .r. �,_.c.a 3 out I. S ,, ill, Il0l: v ill ,:(Ac tx r ons exGt,a€at €rot; ,r ,,} ,, I, t. , _.,. n< )t ., , s,t H ) <As di� not
<br />h.avr,,
<br />an a c°ra,t
<br />o.,, s � . ",rfi „lh4 ko ., c,r rt yon hasc any esu cstons itS,,md ie 10", s � a„ a ...�.::,-,.i ,a., .sC;i, a �s „>-Ii �,� 96 0,"I' %6,,,r
<br />to rbc, BOF a€ d ad,iac. s Bwa,d uI l,,auaU/-term Fu,3 l„ ccs ?a. son, ,'O, �3x , ,_ ,a3, s r.a"�,uts. , ","42) ,
<br />V. Is ..Id:A _.a..L3 Cs,' S,[it (11 il-'a'° i,'xa �ST a311CiMEi c .El) FOR z .a.t _,,a.., Zia. ,S r 0111,Y, :E s,. l.,s�
<br />i3FTITi., 231,(al ,3 E- i6,(A1,11tX<NIAC0.)EO RDG1U'.r,lf0NS.)
<br />e I
<br />by the „b,;re:r ,.ars,.. or,er.nu,, in r,,. t,«k tL, 15.d,,,.� � a�,a `,.a,?v,...,, .zaE t , :,lea �r. ,...,...> � ,.,_.
<br />-T r
<br />atiy I > ,.,., cr sl,�w <6 Wc.l at non l,,tol, um t. S,s ac; c°xarr.Pt fcom this
<br />VI, LEGAL \aHFIC,..1`(.EONAND BILLING ADI RI -S5
<br />Check O'?I° ra ,X iortTi. d re's that at"'ll K, uswal for BO LECMI, A�, IMIJ z CrlTt311 ?t. A11,.NS,
<br />��. "est ,.. "._.. �
<br />TANK O'ttr'YL33C,'-,, Atwalr(sit'lir.,c RE'11'ztl.;J`,NTATIV:;ill STSIGN AND DATT.ITIIEF `1NIASIN1:,C.,.a...:� , J.'S! H ?,X`.,lf .F,: rt
<br />l�)(la)C)It'€`l..11,Luc(:`taAi':lwttlif>,L`ALS?C)E;'�iA<"°)I>T; I�hC'ICiL.,?IiCITS,I
<br />UNIS'lRU£'NON l 0;) ? aIS LOCAL AGENCIES
<br />The c >uwy an un_ sir t,. ata nurnlx ,s are, preslctcrxnnatci and can be obtaiced by lalling the Sta , Brand (916,1221-0"U", nwnOy n" t
<br />assigned by the local a c r k, hoc n cr, this ncanber must be numerical and cararot contain any sale hu c,6, A c aras icrs. If dhe lkx a of ,_,,.y.
<br />the State hoard to tassldr..irs lac:dity ntenber, please leave it blank.
<br />T`I' is "ifs"ll: RESPONSIBILIfy OF DIE LOCAL AGENCY `1`IIAT IN SIIEC USi THE FACILITY Y TO VilR,.l Y THL ACCURACY OF TTIT
<br />INFORMATION,
<br />I'4iIS Aa'i'I..IC :1"I IC1ak CAS �(.7"i° EI ('i ('}C td 3I13I1 iF` 1`ItI; I3tli:: a� C,i 1' i kliliii� I` �{:3"T r`II.I iwi) Tp. , ti 3; I,C :;;a[
<br />AGHNCY IS oi't.t tc3i.>> FOR, THE C°i)1a1i'LE ION OF THE LOCAL AGENCY USE UNLY" I),I°f.}R-MMION BOX AN'D i,,'O
<br />FCJRWAitDi-c, ONE, I0rC I`A AND ASSOCzt? lED T'C)RM I3 (s) TO THE FOLLOWING ADDRESS. ;11E LOC.: T. AGE,'NC Y S1101,31,I)
<br />R1r.'I`Aa i i;:: C. RIGIA,AUS AND ItCifZ44"ARD HE YELLOW COPIESTO O THE FOLLOW111\G ADDRESS, THE MINK COPY :3H%9OLD B
<br />RE' 1, IMED I3YIlly 'I'ANK OWNER.
<br />STATE, E, OF C"AltlltC)I NIA
<br />_ STATH WATER RESOURCES CONTROL BOARI3.
<br />C;'C) SM,l„ L"P. e
<br />DATA PROCESSING CENTER
<br />P,O, 13OX 927
<br />PARA;mtC)U 1`, CA 90723
<br />3195FOR012DR1
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