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INSTIVVTIONS F OR COMPLETIN(*RM A"
<br /> GENh 7.x€1 INSTRUCTIONSo
<br /> SI C"I"TC3 S 27I3 C3I TITLE ILE 23,C`IfAP IT R T 6,CALIFORNIA C'ObE OF REGULATIONS AND SFECI 4'�252$6,25��7 AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CAI_IFOWNIA IIEAL°FII ANID SAFETY CODE%REQUIRE C74l NERS TO APPLY FOR AN UST OP11',R `ZING PI:RMI"I":
<br /> 1♦ One I'C3RM"A"shall be completed for all NEW PERMITRCHANGES or aqy F'ACII I"I"VISI TE INFORMATIONCHANGES,
<br /> 5.
<br /> 2. SUBMIT ONLY ONE(l)FORM"A"for a Facility/Siff,regardless of the number of tanks loeated"at the site.
<br /> 3. This form should be Completed by either the P R.Mrr APP ICAN'T or the L AI.AGEN-CY t`ILDERC"sRC?L,':418''TANK I §PFC"I"CtfL.
<br /> 4. Please type or print Clearly all requested irif'<srrxaation.
<br /> 5. Use a hard paint writing instrument,You are making 3 copies.
<br /> 6. Tank owner must submit a facility plot Calan to the local agaracy as part of the application showiing thi location of the USTs vI respect nes
<br /> buildings and landmarks[Section 2711 (a)(g),CCRJ.
<br /> 7. Tank owner must submit documentatirirt showing compliance with state financial responsibility rc4uirftents to the local agency as past of the
<br /> application for pcimlcum USTs(Section 271?(a)(11),CCR}.
<br /> TOP OF I"(;rRM:"MARK€NLY ONE ITEM"
<br /> fs".',"
<br /> Mark an(}a)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FtAC.II.ITY/SITE INFORMATION&ADDRESS(MUST HE COMPLETED)
<br /> L Record name and address(physical.location)of the underground tank(s).
<br /> NOTE: Address MUST have a Valid physical location including city,state,orad lip wde.
<br /> o°l 1nearest cut and nos ACCEPTABLE.
<br /> Include
<br /> the operator,
<br /> 3. Check the appropriate box f«r T 4 f L C1I BUSINESS 04d]�ERSLIIP(ex.COIiIsOI2A ZION
<br /> 2. Phone number must have an area code. If the night number is the same,write ;n
<br /> SAME" es proper location.
<br /> 4. Check the appropriate bcsx for TYPE OF B(JS.TNESS. T>I VII3UItt«.etc.}..
<br /> 5. If FacilitY/Sitc Facility/Sitsis located within an Indian reservatiotI or other Indira,trust lands®check the box°marked"
<br /> 6. Indicate the NUMBER of TANKS at this SITE. 'I S°',
<br /> 7. Record the E.P.A.;ID#or write"NONE"in€he space provided: _.
<br /> II. PROPERTY OWIN:R IaNFORI ATION&ADDRZ,-4S(MUSTBE CC),\4PLETF 3) `
<br /> Completes all items in that section,un.loss allxitems are the same as SEC 1ON, 1;If the same write SA`V1E�AS SITE"'acresss this section.tiara. Be sure
<br /> to check T''ILC)TaLR`I'Y 044'T�Ii£Zcaii(P`T"Yl'Ti box.
<br /> M.TANK OWNER I.NF012MA I SON&Al)IaICLSS(35UST BE C oM%PLET IiD)
<br /> to chcc
<br /> Complete all ate nss in this sccypE unless all a`tern4 are the same as SEC TION 1;If the:stance,write S INI�E�A;,SI'I`'11'acr0ss this secticxa. IIe s am
<br /> isichcck'I°FtNI O44'NI�12S'T'Yl'T bozo
<br /> IV.BOA RD OF,LQ UA fA I IL)N UST S10R AGE I hla AC COUP"1".t UI BER(M .ST 111,CO."-f'
<br /> b'l Z..I7.5I'sh AR`I'lC l.I;5,C1Ix1Za"t"fsFt ia75,
<br /> L�I�IlSlO:\t"(?,CaAI Il=4iTL'�IA Ill;hT."T'Tl ANt)9AT'ksa'Y CwOhbl:.}
<br /> Enter your B>arni of Equ alination'(13f311)UST storage fc°c sacc:ounf number which is rcq ired fx,fore our'.ni-,`t , ;
<br /> Rei c€nation Beath the Boo will eacseu�e thtat you will receive a quarterly stomad,e fee rettxntiii re coating 1�a a<<'111€cation Cara be prtaceased.
<br /> xttc 5 a s51'p,,iflcns pl.xcd ixa your l.'S'l s._'Tlce,1301 A,ilI axle persons exetra t.from'a r I ,y thw 5(,.}ts.(t,araall+�t>c:r'Il,atk>n ftss; lu xsn'tdat
<br /> 1"VC an ac�cuutnt numbci sound lice:I301:br if yaaia hai:e any TV
<br /> rc>:arcfi r yang the s,wjnit,s,fcc so rvturns will aunt Iles sent, Ifyou'lo-not,
<br /> q €, g the fee or cxenaptic lls please cidl the A`at 916.322 a)fsf,rl car"write
<br /> to the,130l'i at the following address Board of 1,qualization,1ClTaxcs Division,P.O.1.3ox 942879,Sactatsiaxxto,CA 94279 ttE9Q11.
<br /> Y PEIROtIIMlSTTTNANC.,IALR1SPONtiSl13Tl.1I'Y('TIUST'BECOMPIIeIi:DORPEI T20I.Ia\Id,STst.1Nh.A' fi
<br /> OF T'I',T T 123,C:IIA3'TER 10,CALIT ORNIA COIL;OFRE(; I.A IoNS.} l.l. �LC.I IC3tiS 27T3 (aa){ j
<br /> Idc�tatEfy 111atnctn xT(a)u;cd by lite owner sane{/or operator,in msaaing the Federal and Stats,lin.:raci,aI resre 7orisit>ilit ;Siren m
<br /> any Federal Stsatc envy as well as iron petioleurn USTs.are exempt.from,ticis.r cite xtirait.._., 1 y l ualim US"Is owned by
<br /> VI.LEGAL NOTIFICATIONAR;D'BlLI1NG Al�T7T2E,
<br /> Check ON1sBOX for the address that will be used for 130111 LEGAL AND I3IT_l INCJ�C)I lI 1C";A 1IC)IeS.
<br /> TANK 044"NI:TL C)l2 AU°1°T10RI/EI RfE°RI°`s"Iii'4'TIi°I'ftirE.Mt SIT SIGN_AND T11TT'ETTII?FORM AS LN�T;IIC°rA1'I;i:� 51,C:I1C1;tiS 2'fi 1
<br /> (a)(13)OF TI T'T.I 23 C IIAPT I.,'R 16,C:A11 ORNIA CODE O' REGULATIONS.) I4I.L3
<br /> INSTf RUC 11ON FOR THE'I;CICAZ,ACsI aC II?S
<br /> The county an jurisdiction xtuxnlx rs are predctennined and can be obtainezf.tny calling the State Board{916)227 4303; file facilityncambctzna;.Y
<br /> assigned by the,local agency;T oA ever,this number must lxe ainn"ie:rical sand cannot c;ontarsi.any;a3phabeticaT slttaractcts..If the local agency preft:rs
<br /> the State Board to assign the facility number,please leave it blank.
<br /> 11,is a
<br /> INFORMATIONs 3
<br /> f"f ISAt 1'Z ICOF TH'ti CANNOT°IE LOCAL dtNCY THAT H4S_rtCPTS''HP VAC:II.I"1 y 11(") �'L t�IIeY``I"ITL ACtUTt,ACY OF'lift
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOC°AL.'AGEN USE ONLY-INFORMATION BO3C�LAND � R
<br /> FOiL4 ARl)ING ONE FORA"A'°BAND ASSOCIA'I D FORM"I"(t)TO.THE'FOLLO INN ADDRESS,'TI'IEt. ULD
<br /> RLTAIN'1'f IF ORIGINALS AND FORWARD THE YELLOW- TO THE FOLLOWING A DR I'OINK AGENCY SHOULD
<br /> RE'I'AT�I ly 13A ZTTC'TANk 044'14ER. FfE PINK COPY SIIG?ULI)E
<br /> STATE'OF CALIFORNIA
<br /> -STA'T'E WATER RESOURCES CONTROL BOARD
<br /> C/o S.4Y.131.1"S:
<br /> DATA PROCESSING CENTER
<br /> RO. O 52
<br /> -PARAMOUNT, A- 072
<br /> .3/93 ,
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