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INSTRUCTIONS FOR COMPLETING FORM "Al"
<br /> GENERAL INSTPZUTCTIUJS�
<br /> SECTION'71 l OFTITLE 1 i t C.t. .P71 n .`;,CALIFORNIA CC.;DE 01,RE=si��.:=TI NS AND SE.C'a IONS'5286,25287,:�,,ND 2.`289 OF CHAPTER
<br /> DIVISION20,CALIFORNIA f,E Ti;H Al,yii a SAFETY C-fllOE REQUIRE OWNERS TO APPLY F RAN UST OPERATING PERMIT,
<br /> 1. One FORM"A"shat]be c omplcted for all NEW PER CHANGES S or any FACILITY/SITE INFORMATION CHANCES,
<br /> 2, SUBMIT ONLY ONE(,)FORM`A`for aT c.a3ityt tc -cgarTless of the number o=tanks located tat the rate,
<br /> 3. This forrn should h completed by either the PERMIT n PPLIC. NT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4, Please type or print clearly tall requested hlfiormat€on,
<br /> 5, Use a hard point wrifing histrurnent,you are making 3 crlpies,
<br /> 6. Tank owner tna.t sub,'oh a Facility plot plana to the load agency as-part of the application showing tine location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (aB8),CCR J,
<br /> 7. Tani,owner must submit documentation owing cpmpliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petrobe,am USTs[Section.27 11
<br /> 711 (a)_(11) ,C"C"LL].
<br /> TOP OF FOR NP"MARK ONLY ON l;;","Ivt,"T"
<br /> Mark an(X)in the box next to the item haat best describes the reason the form is being completed,
<br /> L FACiLITY1SIT11;INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. Record name and address(phy-sicai locuitm)of the undcrground holk(s).
<br /> NOTE: Address MUSTh ve a aaard physical location including city,statea,and zip code.
<br /> P.O,BOX NUMBERS AR NOTACC EPT'Allt_"E,
<br /> Inchms,flcarcst co),S,st?'ca a ua s-enne of the, fl rator,
<br /> 2. Ph'or e nurnba,roust hare,as aveaa co k. T'$Ta,_r"_:t:t s,a,.ac a. 6s in r.a.oa t E.eca tion,
<br /> 1 Check tree a pr,pr, s box t,a°TS s =4`4i f,._ a S NT" a, .x-;. .L, RPORrt f1 N,INDIVIDUAL etc.),
<br /> 4, Check the approp are box for T ,e , f F f I(,„f',-NS.
<br /> 5. 'f Fa dity/Site,s a c atwd o akin o,I aria-t;ar r ,c ,'a.on or of"hc €.a i ul=r:.,b.holds,Check the box marks d T 1;S", .> .. , ...._..
<br /> 6, Indicate the;NUNIBER e f 1 '"il;r at this "'E l""1E-
<br /> 7. Rio d he 11E1,A II?#c ri[i "n ON it,,hic-,qace provided-
<br /> 11. PROPERTY OWNER'INFORMATION&�,,k'i a ,<E,SS(NMU'ST Eta C,'l'IF, rIS'D)
<br /> Complete all ften-sits this.u c-uo,. rufl.c.ss all.,erne are the iana€.as SECT'ION I. if the same,wr€te^."SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP RSHIP YP 't,c,x.
<br /> 112.TANK OWNER I,`"FOR]IATiC S c a~>t.)REpal(MU a BE,Co yIPI E,I"I.D)
<br /> C canpiete rJ!he .s in Ea;,3. c,.:a,a,,onnicss ad,.a."ars,ar-tFhe saran as AECTION 1,Ifthe sane;,write"SAME AS SITE"across this section;:HBe s}ire,
<br /> to check „c,t„r, OWNERS £ PF>box.
<br /> TV,130ARD OF EDC'ALI,Er,110U US,_`Sli .:a4, a..,a EE ACCOUNT N10411011 tlyIT iS l BE C:0,MP ETED,SEE ARTICLE5,CHAPTER 6,75,
<br /> DIVISION D,l,CATAFORN 1 A fil,:.AL an N'I)"SAFETY a rl:r:';.
<br /> Enter youyoul,Board cf,Ep.pt.,mills .CROP)US-17,.aorage f a�,v.:o 3,tide;]er which,s required befnt"e your peranit application can be processed. '
<br /> egis.,ati;,t woo„H BOF;w"i,=or r,a that a;,fel€rezeive as F a.a.tally ac,rar,er Fee raise b reporting thc per gallon fee due on the nur fiber of
<br /> gallons placed in your E,`,s. T h¢_B01'will dole pera corn,exeraal leasee paying,tb ,tinge fee so returns will not be sent< Ifyou do not have an-
<br /> account;aunn"IeE ,.".th the.BC IE or,f yon frave at,Cr qu e;tm >r ;a,rr' hc fia,or exc lnptions,,please cid 1 the BOE at 416-322-9669 or write to the
<br /> f ll ia,( o'Efgali_aotm.,Fu
<br /> BOE at the ret rasa r cdsU ti rIo<r r, Taxes, t`.tT,F€."„942879,`sa.€r<trt2ento,CA 94279-€)00I,
<br /> V. PETROLEUM US11-x,N`N'(1AL RESPONSIBILITY(Mr-ST B CONIPLET a D r.�()R PETROLEUM USTs ONLY,SIF SECTIONS 2711 (a)(I1)
<br /> OF TITLE 23,CSIAPT A:' e`AL s C:7lZNIA t ODI O REGULATIONS.)
<br /> si:tNS.)
<br /> Identify aie mctliod(s)a'sct3 b'/the owner nntbor opera ur,in rr,ceting the Federal and S€ate txsr ttrtcial responsibility requirements.USTs owned by
<br /> any Federal or Sm, arse icy a:;well rip non-petr lcuot U T:,-, -,.ern="t Roe this r aurae°.neo€,
<br /> VI.LEGAL` O 11M AEI a'T,"ae la RILJJG j',,D
<br /> Check ONE BO Ct,a 01c,,a..lrl.e:., that curl]he a ct "or 130-1111 I.,ws Atw AND BILI,NG NOTIFICATIONS.
<br /> TANK C?ST"NER OR,SC"t`I ORIZ.D.,Cr>PRE E:N1'A I V z MUST SIGN AND DATE THE le;Er( R-M AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(I3)OF"TIT L1-23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.-Ii
<br /> INSTRUCTION FOR T14E;I.O 1,AC:" i t€I:S
<br /> The county andjurisdiction nuneba ,are pt fctcrmincd and can he obtained by nailing the State Board(9I6)227-4303, The facility number may
<br /> be assigned b"a thea 3cal agenmc ra howa,e.,c`as nurrab.,most henunneocal and camlot contaan any alphabetical characters. Ifthe local agency
<br /> prefers the State Roard to is},7.,; v facill"y murnaxe,please le a-vc it blank,
<br /> IT 1a THE _.... .1 _: t,, TO VERIFFY THE.ACCURACY OF TFIE
<br /> INFORMATION. fl al a AF':LICA a ION(-,,, NOT BE r'FsOC,.a ST I)IF R Ile:BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> Ay','F,.'EC., IS RE`PON, BLE', FOR THE y „ ,E'i-.a i l`.SN OF Ti'll' "LOCAL ACst'1'CCY USE ON " INFORMATION BOX. THE LOCAL,
<br /> r'tCL�: C C9;"sr)ULD RETAIN a_s
<br /> THE W INAL AND CE:,I.I,0W COPIES. PINK COPY SHOULD BE RETAINED BY TAItK
<br /> OWNER
<br /> _.a
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