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T 1 FOR COMPLETING ORM "All
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<br /> GENERAL INSTRUCTIONS:
<br /> SEC l lON 2711 OF"I ITLE,23,Ct IAP-HiR 16,C AI.II'rOR IAC ODE OF RECIULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE ISI:[,UIZE,,OWNERS TOM)PLY FOR AN LST C}PE ATI G I'RMIT,
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT C33ANIP S or any FACILITYISITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ONE(1)FORM"A".for a"Fiacility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by either the PERMIT APPLICANT ortheLOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested inforrneation.
<br /> 5, Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landniarks[Section 2711(a)(8),CCR].
<br /> 7. Tank owner must submit documentation shirring compliancewith stag financial responsibility requirements to the local agency as part of the
<br /> application for petroleum UST's(Section 271.1(a)(I 1),CCR],
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<br /> TCP OF FORM:"MANIC ONLY ONE I"I EN11"
<br /> bark an(X)in the box ne)Lfto,the item that Ix:st destisibes the reason the form is being completed.
<br /> T; FACILITY/SITE FACILITY/SITEINFORMATION aft ADDRESS(MUST BE COMPLETE D) r
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and zip coale.
<br /> .O.,BOX NUM13E RS ARE NDT ACC F'.I`'1'/BLE,
<br /> Include nearest cross street and name of the operator:
<br /> t Ph" e number r trust Nve an area code If the night number is the same,write".SAME"in proper location.
<br /> 1 Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,,INDIVIDUAI„etc.).
<br /> 4. Check the appropriates box for TYPE OF BUSINESS
<br /> 5. If Facility/Site is located within an Indian re servation or other Indian trust lands,check the box marked "YES",
<br /> " & lndic,atc.the`PvUhll3`ER of'1`A S est this fsll I, �.,
<br /> , . " I`i. ra i + , ``t`e r, i`. : , ,
<br /> 7. Record the E.P.R.ID#or write"NONE"in the space provided,
<br /> H. PRCOttI;i1ZTY ONV4'ER IaY1-C7RMA"116.6£u ADDRESS(Mus'''BE COMPLLT: )`
<br /> Complete all items in this section,unless all items are the same as SEC17ION 1„If the same,write"SAME AS SITE`”across this sectiom Be sure
<br /> to check PROPERTY'OWNERSI1111TYI'E txrx.
<br /> 111 TANK OWNER INFORMATION ION&ADDRESS(MUS I BE t ONIPLLT ED)
<br /> Complete all itt[pain/ttsv\((in this
<br /> )((s�ccttion,utt3c;,s all ilerns are dw same as SEC17ION 1;lIf the saatac,ur.ie"``SASS(:r�S Si"I'l"acresss this section I3c stare '
<br /> to C't4cck T AN \>Yp S:.d�.J I .fY lei;hi'.X. 4
<br /> IVBOARD Of- 1 t h'AC C C)i;e I N Mf31"R('01,STBE C;OMPLEa IT..D.SI':1:ARTICLE 5,C1IAl"I I W(o5,
<br /> DIVISION 2(),CAI.l1,011NI*IlHAL.111'i,NO SAVi:T COD .) j ,
<br /> Enwi:your Board of Equal;,ezi4m(W)Il)C.S'I`st,,fa;c fiat acco;ra nail brlt skhI h is rquiled before yourlx nnit aar,,l.cat,r;n call be p occsscd.
<br /> Rcgwl at.on wiih the BOL,will er sure.Flat you will r.ee[vc a quacterly storage fee return ut repord,ng the SWAA{Cat nill )} r gall*<n f:,e due.on the
<br /> number or gallons placed in your UIS I's. 111,;Bolo wiA code persons exempt from paying die o,oi p e feu:so rauuns w"I rot be start. If you do not
<br /> have anaccount nunilxr sa tt;tlrclB01",Tar 4}`anrlaawu {tty',questrons rcg;"atuinl the fee Or cxcrm 6on" I h,,a.e�-t all tlxs I10F at916,32;1 9&r)or write
<br /> to the BoE at th"foliowh'g a dre:=Board Of Equali)at9oai,14re Taxes Division,11.O.Box 9421S79,tSacraneirto,CA 9 12 7910001.
<br /> V. IIETI�O, 1 t Ml U"IS I`H NA C.IAL R PSIIONSIIll Lht'Y I'131:CON! FOR lads"IIW)l 1CM US-Is ON Y,S1i.1 SI:C]iONS 27 E 1 (a)(9)
<br /> :Id t t v tat'gfso i}iCx.(s),els.:d is In,-,o tiera lion ErttartE=;,t m'c"wig;t:ac 7 e.d"raL And ..zK2,x.t<at:eial. ara,�etsty t.�) ra,�ttr�r.t.;.wUS I's uss�::",d t;g
<br /> airy t""I<Dttalkof 4tai„t.ae:.t.,l as tst.11 as rlon pc,aro, onr US I s arc exempt 4r,un this.Cott,t,rtae,;ti,
<br /> V1,LE AI °etaTIFIC, l`ION AND BILLING Alv,IX, ss
<br /> Check ONE BOX forth, a'li ss lh;it will be ut cd for lIC)TH LEGAL AND BILLING ING\t:7 WIC;A]lf,y.)(�OS,
<br /> TANK OWNER OR1r AUTHORIZE'!) CIi;I't t.sl:e`I�"i ii'I MUS I'S Ce:4 AND D X E—f I?t,'FOIC\f AS INi)IC A.ED, ,Sr,.,SECTION'S'2 11
<br /> (a)(13)OF-I'll LE'23 C l IA11 ER 16,CAL11,01ZNIA COT,)Il Cal'RI.,(,lt,LA'I'IONS.l
<br /> The county art-Jurisdiction numbers are prctle,termined and can be obta aced by c:alli l the Scitc Board(916)227-4303: ITu;Iae:ii ty number rosy be,
<br /> assigned by the ro.:al xfa ncy;however,this number rsaust be,nurnerical and cannot conlain'any alpltatsetia<btrcharaclers; if dict local agorcy prcafers
<br /> the state Boa„z to ay igri the faci+,y nwnbcr,please leave;it blank
<br /> I°1`15 T"Ills 1Zt,S.'t) S!iili.I1`Z' o)I T`?lE 1,0C-AL.AGENCY THAT INSPECTS 'Lll's. AC,ii-IT'Y TO VFRIFY THE ACCURACY 01"TIIE
<br /> IidI=C)]dMAT'ION, °i'IiS i Al's'I,It..A"I'IC)ti C`<1\�>.1 a3I:1" C3C L5 la`i)Ik' I`tif 13{>I ACCC}L�I°°eL l d3l.i C IS'C)T`I`II..I,Pw)1�. "1'lll 1..f}Cr1I,
<br /> AGENCY IS RESPONSIBLE FOR THE t:`tTtaSPLET'IO CSF THE "LOCAL AGENCY LiSE ONLY" INFOWNIATION BOX AND FOR
<br /> FC)9r'WARDP) Cf ONE:I,OR 1"A .'illi:.)ASS:}CIATL D FORM"13"(s)TO THE FOLLOWING ADDRESS, THE LOCAL ACiI NC:Y SHOULD
<br /> RETAIN Ilii:01RI at; AL-%AND`I'"'>"t2W RD TlIL YH*LLOW COPIES`I'O'ITIT:FOLlm0,WING ADDRESS,HE PINK COPY SHOULD BE
<br /> Rh1AINEDB I"lid, IA'SROWNER.,
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<br /> FOP1010M
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