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INSTR*I-IONS FOR "A"
<br /> GE F:RA1,`INSTFtL,i "i"IONS:
<br /> SIFC`I'1ON 2711 OFTITLE,23,CHAPTER 16,CALIFORNJA CODE OF REGULATIONS AND SECTIONS 25256,2.5247,AND 25259 OF CIIAP I'ER
<br /> 6,7,DIVISION 20,CALIFOIt:NIA IILA1:`II AND SAFETY COD 4sC DIRE;C3G'dStiERS TO APPLY FOR AN U T OPE Rz"TANNIC Pf,,R IT,
<br /> 1. One FORM"A"shall Fes completed for all Tv EW PERMIT CHANCES or any FACILITY/SITE INFORMAnON CHANGES,
<br /> " 2. SUBMIT ONLY ONE(l)k`(,1RM"A"for a Facility/Site,regardless of the number of twills located at the site.
<br /> 3. This fora should be completed by either the 1'Elt'.41T APPLICANTor the LOCAL AGENCY'T NDE:Tt4IItUt7"vD TAISK INSP C:E`OR.
<br /> 4. Please type:orprint c°lroarly all a rluest.ed infoonation.
<br /> 5, Use a hard point writing instrutricnc,you are making 3 copies,
<br /> 6. Tank owner must stt6not a facility plot plass to the loam agency ars part of the application showing the location of the USTs with respect to
<br /> buildings and Wid arks[Section 2711 (a)(3),CCR).
<br /> 7. Tank owner rr x, t sublon doeurn rnarion showing compliance with state financial responsibility requirements to the local agency as purr of the
<br /> application for petroleum USTs{Section 27l?(a)(1 l),CCRI,
<br /> TOP OF Ft RML `:,YSARK ONLY ONFF I"T L,rT,.
<br /> Mark an(A)in the box next to the Tian dais best describc;IIsi reasca;s the form is being completed,
<br /> I. pACIE.:L"1 YY/SITE TNFORI 1ATION&ADDRESS(MUST BE C ONIPL:ETET3)
<br /> 1. Retorts name and address-(physical location)of the underground tank(s).
<br /> ITC)"Il;: Address NIUST have a valid physical location including city,state,and;rip code,
<br /> P.C3.13 OX ISU NIB ERS ARI;NOT ACC EI'I'A Bt;E?,.
<br /> Include nearestcross strce.t and name of the operator,
<br /> 1 Phone number must have an area Crete, If the night number is the same,write"SAME"in Sniper location,
<br /> 3. Check the appropriate box for'E`YPE"OF BUSINI,'SS C,ek'1*ERS IP(ex.CORPORATION,INDIVIDUAL,.etc),
<br /> 4. Check the appropriate. box forTYPE OF I'3C.SINIilSS.
<br /> 5, If Fa dity/Site is locatort within an Indian rmrvation orotherindian trust'lands,check the box''marked"'YES".
<br /> 6. Indicate the NUNIBE'R of TANKS at this SITE.
<br /> 7.;Record the E.P.A.11)4 or write"NONE-in the space provided.
<br /> El: I'ROI'IvR i'Y OW.Nt,,,R i.NFORMA 1`LU &AI)I)RE'.;SS(Id'IUS'I B I.,,,C'f>1 PI,l,'TF' )
<br /> Complete all iterns in thissection,unless all items are the,same as SECTION to If the same,write,"SItME AS SITE"across this scctim. Ile sure.
<br /> to check PROPERTY OW'EWS'iI`_P TYPE hox.
<br /> Ill.TANK OAVNERINFOR)AA"t'ION�Al)DRIL';SS(MUST BE C:OMPLET�°I�si))
<br /> Cc>m l-te all£tans in this section,untess all items are the same as SECTION 1,It the:-lame,wrue"SA`IF',AS SITE"across Lhii,stiction. Be sure
<br /> To chcc;k,rA.N K OWNERS"y PE,box.
<br /> IV,BOARD OF EQ Al MA"IO—NUS l'S'l ORA('113 I l E AC.COUN F NL't"IBF' (MU'ST 73Ii COy'I"LE'1FM,SLI'ARTICLE 5,C'fl,Air I i;R 635,
<br /> DIVISION 20,CALIFORNIA.t 1A TILI,A1,11l AND SAYE.'f'Y C01A .);
<br /> l'lnn"'r your t3s).aR3 c'Equ'adizatiota(BOE)UST s.caragc tea accryunt rtrarnb r A'ic a r �u..r.ed NEore yo,,voi,r porn ale ap plicatr<.n cam Ile processv&
<br /> Itr,stra,icrz with trate B01,evil c°ns..are that you u_I,i rcceivc a quarterly s o.at c fee to axn in repol-no"111,.50,11 s,(.nn lks a c sy afhxs fe"...Clue on the
<br /> - nuarrtt,,y of mate n,piacncl in your 1.,4 T s. "lies BOE v,all code persons exe,npt from E ayin,.hc s€or,igc,fac;sir feta€gas will nut h� %i ;,s_ If you do rebs
<br /> have. an account tat nnbcl wait trite B01,ui ii you have any questions regarding th,fee of cexc.s',p,:st,s,Cala„ase,t nail slag BOE<a 90 3212 'TCaf 9 or wr rc
<br /> to the BOE at.°slit food', :Ing ecttl3,,..s tic alts of I;;quakx.ztion,Fucl Taxcs Division,11.0,c3ox 912WN,4ncraarn"'wo,CA 94279 00l)l.
<br /> V. Ill,"I IZC)1.T.s.M l'ST ITNA.NC..IAI,kt.,SPONSIRU,.;Y(MUST E3I.CON1111"I"ES)FOR PEDROLEUM teal I's ONI.t,Sl��l iEC.i IONS
<br /> OF-FI`SLE 23,(-11APTER 16,CALIFORNIA CMDE'01 RiX31 TIONS)
<br /> Ielc:n_,ly t>;: r..,l?rz,a�s}t, z d;ay tttc av,.acr at.el,>r C3Lac errs,r,in nt,.c,t!rtg the I ettUral a;iei Stilts fsa,.r.raa t�.l c�r,:':c E, x,_la, ,..ra,raam 1U11
<br /> any L „r.! .S,s <:I;ra .y as,vck a<noll jab ttoleuto 1,S'I s a c cxcrr.grt from tlaEs rs,ckaa. retests.
<br /> Vl I,FGAIII NO'l i`l(','Y NON A',N-I)1311T,a.vG ADI)RES
<br /> Clic, 0 v:F T t'),"i fear the .d=rc s�hi a will be usid'Or 130)I'll LEGAL,AND 131,11ANG,NO t`WICAY TONS;
<br /> T-AI'eK OWNf'R OR AUT111 )l.:MMI)RE:I'1'�§.�sar,'�TA Ik'"Fit ST SIGN;Y.ND I)A T�I:`11IF('C R.M AS INDIC,a;I�;�.l.:).', ['�,.I.;..'i' 't,C,,4a,.;f I;
<br /> Rh
<br /> (a)(1,3)OF T11i.:!I,Y
<br /> I l 1, .23 PTE'R 16,CAI,1i(,.)R IA CODE CS Rl,"GUL.al IONS,)
<br /> .. �T-NNaJ1F\UCTIO.w t`OR Iil"LOCAL AGf.NC.IF.s ..
<br /> Th; c,tt taty an jurisdiction numlx..,,-e g:rcdctemnirttsd and can be obtarocd by calling the;State Board(SIO)2271-4103. Tne eaa:i1, a number may,>F
<br /> assigned by the local ilgcni ,hc,cacacr,this number must be r canersc.al and cannot contain any allphabodcal characters, If the local P,g cmcy f.aelcr x
<br /> the State Board to assn . ac faC i[y nurnber,please leave it blank,
<br /> ITIS if:i RESPO SIC3I TTY OF TTI_ LOCAL AGENCY THAT INSPECTS THE FACILITY`1'() VERIFY THE ACCURACY OF ?=l
<br /> Iy FORM ATION. THUS APPLICATION CAN Car I?l:PROCESSED IF THE BOE A COUNT NII49BER 1S NOT 1'I t LED IN "I III:LO(} AL
<br /> AGENCY IS <?1.`sI'0NSI131.1t, FOR THE CO-VIPLE1'IO OF THE LOCAL AGENCY USE ONLY' INFOR4IA TION 13OX AND FOR
<br /> FORWARDING TNG C)N ,FOR'VI A SAND ASSOCIATED FORM"B"(s)TO THE L`C3I.LOWINC3 t1DDREt:`s,. "E IIE I-(,)C.AL A()F-N�C.,Y SIIOUI.I3
<br /> BE'I Ale"bill:ORIGINALS AND FORWARD THE YELLOW COPIES TO THF FOLLOWING ADDRESS.`111"-RINK COPY SHOULD IIF;
<br /> RET.AINED33YTilT;"€'f1NI Of , ERS
<br /> STATEOF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C10 S.lY 1.a E.Ers.
<br /> DATA PROCESSING CENTER
<br /> P.0,BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3.'9.i
<br /> FOR012DRI
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