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INSTRUCTIONS FO LETING FORM "A"
<br /> GENERAL INSTRUCTIONS,
<br /> SECTION 2711 OF"I t 11 E;"23,CI iAI''I`i'R 1 Ci,CAI,TrCOR 'IA CCI33I OF RE GUT,A IIONS AND SECT`ONS 25286,25287,AND 75289 OF CHAPTER ,
<br /> £7,DIVISION20,CALIFORNIA III ALTII AIND SAFETY CODE REt DIRE OWNERS TO APPLY FOR AN UST OPLRA'nNG PERMIT.
<br /> 1, One FORNI"A"shall l--cl.an,rlou-i for all NEW PERMI F C 1ANGES or any` ,..al.e :€;,x1=`...N F,,)Rf,1ATI0N CHANGES.
<br /> 2, SUBMIT ONLY ONE(3)FORM"AF"for a Laciizty She,regardless of the nurylber of t k,e located at the site.
<br /> 3. This form should be completed by either the PERYIET APPLICANT or the Lt a AI,AC=F,NCY UNIDERGROUND TANK INrSPES .3�"',,
<br /> 4. Please tyles or print clearly all resat c:tod inforanatic»t.
<br /> 5. Else za heard Ix;int writing instrrisrte nt,yore at,,,,making 3 copies,
<br /> 6. Tank owner must sobltn s a facility plot plan to the local agency as Part of the application showing the location of tbi U Ts with respect to
<br /> buildings atol landmarks LSci bora 271 i(a)(8)>C C RJJ ,
<br /> 7. Tank owncr must s llisl t d z....a_.,¢ntation showing oc and li ance with state f;aaaancial responsibility requirer a te to the lace agena,y as ears of the
<br /> applanation for petroleum E'STs 1 Se ctisstt 2711 (a)(11),{CRI.
<br /> TOP OF;FOR :"MARK ONLY ONE,ITEM"
<br /> Mark an(N)in the box next to the S, na that K st describes the reason theform is being complCuld,
<br /> L F'ACILd YISITF INFORNIA11CN&ADDRESS(MUST BE COM[IL.E' °D)
<br /> 1, Record naine and address(ohysig al laaeis ct)of tile Underground nk(s).
<br /> NOTE. Atldre ss NAUST have;a valid phys.cai location irtc;ludi isg 6ty,smtc,and zip code,
<br /> RO BOX NUMBE'.ILS ARF N€3'1 "iCC.>"l FABLE.
<br /> lm;ludc nearest c,osslnct and name of the operator
<br /> 2, Phone riz mbeA aacuit have,an k.ca;ctdv. If the night tiuienber is the same,writ"S x".41,'°in proper Iodations.
<br /> 3, Check the appropriate box for't'2II,taAr lis, zSLtSS c.> N1,".13SHIP(ex.,CORPORATION,RIDIVII"7UAL,etc,).
<br /> 4. Check#lie appropriatc bcsx fol,1,Y111,11 OF Bl"ISLINESS,
<br /> 5, If Fay i.lityfSitc is Itic awd within art Indilan reservation or other Indian,trust lands,check the box marked"YES".
<br /> Ci_ Indictite the NUMBER o[TAldKS at this SITE
<br /> 7. Record the L:RA.11)#or write NONE"in the space provided.
<br /> IT, PROPERTY OWNER IN FORTM ATI ON&ADDRESS(MUST 13I COMEL.E1`FD)
<br /> Complete all iterns in this sccdoaunlc.,s all iterns are the settle as S[-'C'IION 1,If the same,unite"SAMF AS SITE"across this coctiom He sure,
<br /> to check PROPERTY O'0 ?;aRSi1[P TYPE bo
<br /> LIT.TANK OWNER ENI`ORM l 1C)N&ADDRESS(MUL S I I3E Co mliLsE 1`E )
<br /> Complete all itc°ms in this rcct.on,unless all illetns are the carne as SFICIJON I,If die sasnae,write"SAME AS ST.E"across this rectitai, Be sura
<br /> to cho k TA K C)sit'N" S 1` lel,latex.
<br /> IV.BOARD OF le1QL;ayi..IPay'a ION C S'r : 10'a Ci t,.._a AC.COUTNT 1*U4IBER. (?a"US T' E COMPLETED,SEE f XI-IC;LE s,CI1Als'rER Ca.75,
<br /> DIVISION20,C°.ai1IF:SRNT 1 IlEALTH AND SAI"IITY CODE,)
<br /> IC-nit, sots I3c .rd of Tx1us . ..-a(3C:--)i,ST somige fee sacccisss,c number whi.cli is rUdacircd blAsae uunt-pA!nn i ap-1hCa4.:on C11 be p,c?r,r.;ysaal,
<br /> Regkl l a.ion°l ctI.the WOE .rt ei.s .c fiat you wii,l reecive.to.1t,arledy<a or a,gc Ire return s?rllpoiting the S0,(g)6 ibini.l i per teedb"cl fe',;dins°,an the
<br /> in L 5 l s lllc li,1I mall t cxks rx rsor,s frorn paying ar slono,_fe s€ora,_„ns ,r:ad not t._,sane. It 3'tsl do meta,
<br /> have an cl, .,r..; IXAE or i soli have any stat".rc:is sex rdil,g the.cU r=r xs x,.(W* ,<� .,w.,.a.l a,w 1,c`)s. a;9 ICa 2�All
<br /> tht,.l,C3stere Hoard o 1W:I3u�.a illation,F'uyt]Taxes 1 wis;dcxr_,P,,0, 4oxP .),i87', ae.a:w/nto,(7A 94 e, 00110ly.
<br /> V. PE>"(9�O FI—a 1 i S I't�it1 '111L i � ON SIIIiLl E 0411"S'l 131 (T xDaLLE-11,� OR PE to .d 031 :F3.t.Ji y v3 i �� �11 �(
<br /> OFa`TI:1�L E 23„C.`t', .'I IaC ,c Ays,;.v.°,ti„r )i) CI aLf°< ; iter >tU `.3
<br /> Id;:r, t>,;;e r=,.t.tEtd(sr v�cd t y tI �strticr a,c1'.,,csa,a s,,in i to the;I^ d nal it t S. Lc .,a,.a,tr sal e riar.;il ,iz; r�.<lct �o ants,ISTS s ora .,.1 by
<br /> a31y f_..cIta or St—Ii"',ag a_c.,,.,:v,Uzl as.;fir I'ouoIClint L'SI's arc;cxesdp€from this a<ras.e.me t.
<br /> VI h1:GA% NC}1ll�it.'y?'Ii)N�"317I31E_I�INta A1?ty€dFiii � _ . �.
<br /> Ctiec°k fJly"Ii llO�i{>r d,,.al.dre;s tliat ssi1'1 kis;tzsrrd for IICI`7{3rd;ia�1L s�"�17 L'I1..I.L'SC^ft)i'Ii°'1C't"t°t�lt?`�;`i.
<br /> TANK OWNER OR AhTltORIfil l3FPREISI"NTA`9'Ix1}):3MUSTSIC'N AN, 'Ia'r1d}3"1`11F FC:)hy/(AS INDICA°IT'D.
<br /> (a)(13)t?F"LI'I'L,F:23 C HAP"l`l R 16,CAl_ItO NIA CODE OF'REGULATiC3NS.j
<br /> INSTRUCTION FOR'CITE°.L OCI°AL ACaI,NCIES
<br /> The county all jur;sdictiori numbers are predetermined and can be obtained by calling the State.I3o4rd(916)2x27-4303. lbe fatality nss nberm ag be
<br /> assigned by the litca'l agQncy;hooever,this number must be nit rlIoical and cannot,contain any alphabetical characters, If the local agency Prefers
<br /> the State E3oind to assign the facility tianraber,please leave it blank..
<br /> IT IS THE RESPONSIBILITY OF TIlE LOCAL AGENCY `IT?AT INSPECTS THE FACIT.ITY'FC3VERIFY THE ACCURACY f)I^"'111F,
<br /> INNrFCITehCa'C`IION4 I HIS Al'i'L ICATION CAN NOT BE PROCESSEM IF` HE BOE ACCOUNT NUIMBF.R IS NOT FILLED IN, THE LOCAL
<br /> AC31.'.°°aC,Y 1S LII'Sz't:):e`;1T31_I I1OR TIlE C"CBMPLEut"Ic:1;a OF THE: -LOCAL AGENCY USE: ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING DING ON'H FORM"A"AND ASSOC'IATEI?}°'C}RM"S"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN`FTSEORIGINALS AND FORWARD THEYELLOW COPIES TO`HIE FOLLOWING ADDRESS.'111E PINK COPY SHOULD BE
<br /> RE AINE'. BY I'Ill, PANIC OWNER,
<br /> STA'T'E OFCALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/0 S',W.E,E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.0) BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3793
<br /> FOR0120PH
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