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INSTR*IONS FOR COMPLETING WINI "Alli
<br /> GENERAL INST UiCTIONS:
<br /> SEC;°1'IO 2711 OF TI"I I L4 21,C~I1AP TER`A,C ALIFOR!'N`IA COLE OF REGLtLATIO S AND SECTIO CS 2-52,86,21,5297,AND 2,5289 OF CHA[aTER
<br /> 6.7,DIVISION 20, ilb I;FK A.ND SAI^^� CODE REQ IRE3 OWNERS TO#E�ElI.'I:FOR AN LIST OPE'R.ATLNG PERNUE
<br /> 1, One FORM"A"shall Ile lurta it ted f.,-.11 NEW PERMIT CHANGES or any FAClLFFY/SITL^:INFORMATIOI�CHANGES,
<br /> 2, SLII32v IT OIC LY ONE(1�Ek)i2_M"A"for a Facility/Site,regardless of the nuruber of tanks Located at the sue.
<br /> 3: This form should be completed by either xlte PfiRIvIFF APP ICANT car the LOCAL AGENCY UNDE' C3ROUN 2 TANK INSP C TO13
<br /> 4.Please tyle or point clearly all rec}iaested information
<br /> 5. Use a hard point,writing instrument,you are making 3 copies.
<br /> 5. Tank owner moist submit a facility plot plan to the local agency as part of tine application shelving the location of the UsTs with respect to
<br /> buildings and tat dmarks[Section 2711(a)(tg),CC RI..
<br /> 7. Tank yawner raw,submit documentation showing compliance with state financial responsibility rezltain meats to the local agency as part of the
<br /> application for fxy leum USTs[Section 271?(a)(I 1),C:CRI.
<br /> "T"OP OF FOR h" ARK ONLY ONO,I I'h.°:1°'
<br /> vf!irk an(X)ijI the box next to tine i ein t;n.at best desc:ribd the reason the four Is being completed.
<br /> L FAC:ILITYISITE INFORMATION&ADDRESS(MUST IIF COMPLETED)
<br /> I. Record tame and addrepss(physical location)of the undergrouand tank(s),
<br /> ?vCkTET Address UST have a valid physical location including;city,state,and Zip code.,.
<br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest crass street and name:of the operator.
<br /> 2. Phone number must have an area code. If the nightt numIxr is the same,write"SAME"in proper location,
<br /> 3. Check the appropriate box for TYP OF BUSINESS(1WNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4 Check the appropriate Ixix firTYPE OF BUSINESS.
<br /> 5 if l dltt ls.Et ts'oc atcd oithin an Indian f scrvattpta pr`oLh t� cFaaa mast Ia ads I � �csa�r ci"YES",
<br /> 6 Indi°° t t]ac Ntl lBETof IAIN S at at is
<br /> 7 g>c
<br /> P � ythu,E°.?.A,l)is or cerate"NONE"inthe space provided.
<br /> I.I.: I'KOP',-R'I'Y OW"`fl R L\l ORMA'1'10,N ADD1Il,SS(MUS IIF,coNfPL pTFI)) � a
<br /> Cornphtc: all he'n's in this section,unalcss all Items are the same as SECTION lig If t c spanc'„ rail "SSS„,AS`I?.< <a<<rzl_s tl.s, _,..txc , Ile,sort;
<br /> to check PROPERTY C� �IvisSa'x:i''fYI'L Ex3�.
<br /> IIS.TANK£3WNER.INI ORMA[ICI\&c Al)DRE"l s(S111S,T BE C:OMP;;1 I -D)
<br /> t`eample,te all itta ns in this sCcticn,unless all itctns'are the space as SECTION 1w If the sa.t2e,n r„_�. SA,*at.AS d:6ssecllot,. lie scuta
<br /> to check TANK C)WNERS TY1'E boy—
<br /> IV,BOARD O T QU.11_`.`f.A'iON U- i S'IORAQE.I"TI.`(AC:C(3UN ;,Tl MI3P.E2()1t.S£ lnW CC3"';1 l—EITII; ^[.t. ART,t„tills,Cal,'PI R 6,75,
<br /> Enter;,.nun lion of (R )I)Us i`lltortgt
<br /> 133Ol",vvsi't cc',.cue thzit v,;u ,est receive ive a ow ar erly }>.Yn,
<br /> ,-
<br /> hate zln accoujit lltlanbc, tt lhOEyr i”you I=avc sny sisiestteanlst;as!cc m pl s 916l.t ,)66) o, Ar.: �
<br /> to lha Fc)I.at.Il, ia>.(,a4g41g,at9ut; ..I3t el art Equ �atno:i,Fu 1 1 aa�s 1)n .aacAn>t'.t 3, stip is l
<br /> x r -h*. a rip s a• s z`IY t ,I_ >r FOR > 1 1
<br /> �'.. k,_lft..�i.i_..,�1 �.;'�, <i• !.x..,C„1I_:�a..�.�}..�.,.113;c,a t�,..,�1 t_--i,<C,.�d�lx«..l,al:.d.).ves�.�..:�{,�,l,�.v l;Y'��t,:^+,, tf;"< >., �,.ikt,(
<br /> C11"'TTI'L._,21,CHAPTER 10„C A1,TI€ R'NIs1`CA{JL l CPi JZ..Cs11Z OI St ?�,:j
<br /> ldcant.Sk thy,salt.chIks)a cd kg.,hn',ownerarad;or` p n.xt©,r,in niz airzg the Fedc°nal ani Sl_aav is, ,.,t k_., ...,� �,yc,i. :..,tea. i .
<br /> a nv Fedclalof be<.i Cn,:y as vrcll as non-petsulcurn I,STs rare exempt from thls.r.{t sscr..er.,t,
<br /> VI,LEGAL;SO II1r1CATION AND BILLING ADDRESS
<br /> Cla, k ONE LC)h:for t`znc.,d ress that will be used or BOTH LEGAL AND BILLING?,'O'l II ICA'llONSc r
<br /> TASK OWN ll,OR AU I10 IIE:D RfillRESE.NTATIVF M{ .ST SION AND DA I L Tltlt;101 tl AS. DiC (.':i), i.St_ .S i,,C i a(..s 2,1 1
<br /> (a)03)OF TI'T Til:.23 C:,11APTER 16,'C:A1.1taORNIA CODE O' i EGULA I'Lt3NS.i
<br /> INSTRUCTION 1,011 l NE LOCAL AL.AGENCIE1,S
<br /> The cc>nttnty an nutn'x rs are puci3ccerinoned and can be obtairtcci lag-calling the;`i:a.c,11w,-i )3(,j w'.'2, 4!03, ,�,< 1..,iA:k z
<br /> assigned by the local agency;hos%ever,this mun be r nmust be numerical and cananot c.otntani:as,g alphub ts„aT characters,
<br /> the Mate Board to assig;ta;Ine facility number,please leave:it blank.
<br /> 13'IS`I HE RESPONSIBILITY OFTIM LOCAL,AGENCY THAT IItiSPEC.I5 TETE; FACT -ITY 'io VERIFY THE ACCURACY O "t`H
<br /> INT`ObZMATION, THIS Al'ikl._IC�ATION CANNNOT BE PROCESSED IF TIIE 1301-,ACC'C)CII°T�� aN`ilMBI R iS,',,;O '1.1111. ,D IN. HE,"LOCAL YS CAL
<br /> AGENCY IS RESPONSIBLE, Fok E'EiE CMP OF THE "LOC"AL AGENCY USE ONLY” INFORMATION BO IA:
<br /> AND FOR
<br /> F&OI �'ARI3 NG ONE'FORM A”AND ASSOCIATED<FORM"H”(s)TO TETE FOLLOWING AI)DRFSS. TETE LOCAL AGFNC Y SHOULD
<br /> Rl:.'l'AIN THEORIGUNALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWLNG ADDRESS.T11E P I:NK COPY SHOULD BF
<br /> u
<br /> STATE OF CALIFORNIA
<br /> STATE WA'IT%RRESOURCESCONTROL BOARD
<br /> C/O S.W.E.E>.P,S,
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> I'ARANIC3tI°a``P,CA 90723
<br /> 193 FOR0126R1"
<br /> j,
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