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INSTRUCTIONS FOR COMPLETING "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF"I I I'LE"23,Cl I Al?TER 16,CALIFORNIA CODE OF REGUTA ITONS AND SECTIONS 25287,AND 25289 OF CHAPTER r
<br /> 63,DIVISION 20,CALIFORNIA klrftE rlf AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING k'Sal MrF.
<br /> 1. ()Iiz,I'C9i2M"A"shall be completed ted fear all N EW PERMIT CHANGES or any FACI LITY/SI`f'k:t14 i"s RIMA'C ION C}IANCE&
<br /> 2. SUBMIT ONLY ONE(I)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 1 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TAMC INSPECTOR.
<br /> d. (please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,ent,you ate making 3 copies,
<br /> 6. Tank owner roust submit a facility pleat plan to the local:agency as part of the applications showing the location of the USTc with respect tai
<br /> buildings and landmarks[Section 2711(a)(S),CC J.
<br /> 7, Tank owner anust submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petrolcunt USTs[Section 2711(a)(,I 1),CCR],
<br /> TOP OF FORM:"NIARK ONLY ONE ITEM"
<br /> Mark an(h:)in the:box next to the item that best describes the reason the form is being;completed, "
<br /> -T. FACILITY/SITE INFORM A"ITON&ADDRI°SS(N,.1UST BE COMPLETED:)'
<br /> 1. (record name and address,(physical location)of the underground tank(s).
<br /> NOTE: Address 1IUSThave a valid physical location including city,state,and zip code.
<br /> 11,0BON NUhIBEaRS ART-'NOT ACCEP-TABLE.
<br /> Include nearest crass street and na.ne of the operator.
<br /> 1 phone number must have an area code, if the aright nurmxn is the sante,write"SAME"in proper location.
<br /> 1 Check the appropriate box for TYPE OF EuSINi SS OWNFR aliilx x.CORPORATION,INDIVIDUAL,etc,).
<br /> A. Check the appropriate box for TYPE OF BUSIN1:S&
<br /> 5. If,Facility/Site is located within an Indian rescrvation or other Indian trust bids,check the box marked"YES"
<br /> 6, Indicate the NUMBER of'FANKS at tints
<br /> 7. Record the I"T.A,ID#err write NONE"in the space provided.
<br /> If.. PROPM: TY OWNER INIacJt?SlATION els ADDRESS(NILiST13L COMPLETED),
<br /> Complete call items in this section,unless all items are the same as SECTION 1,If the same,write"SAME,AS SITE"across this scetiont Be sure x
<br /> to check PROPE'RT'Y OWNIiRSIIIP TYI'1';box,
<br /> II1,"TANK OWNER INFORMATION&ADDRI..SS(NMUS l'BECOMPLETED)
<br /> ED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE-E-<ac ross this section, Tat,sure
<br /> to check"PANIC OWNLRS TYI'la box.
<br /> 1V,BOARD OF LsQUAIIZ TION Lei"I STORAGE FE ACCOUNT NT a BE,12(4 UST BE CC)'4 P Ifli_l7.SIL ATtTICI':,.5,C,li, VIT'R 635,
<br /> DIVISION 20,CALIFORNIA 111aAL'I'li AND SAFETY CODE.)
<br /> Inuer your Board of Equal,zativn(W)h')C;s i sto;agc fec accocant number which as re;uircd before your p nr it aI pliclation her Iare,cc:E�c 1.
<br /> l ugistrati,)n with the BOE Nvill ensure that you will receive a quarterly storage fee return in rctroning the`�OJX)6 ibrr;ia ,a scr,, .I�ar:fee due oil Tile
<br /> nurnber of gallons pl ac cd in your USIs, I art;13011"will.code ptnsuras exempt fre+an Paying the.twr.age fcc so sctuen, w,1., a be If},,aa do not
<br /> have,an acecount nurnbcr with the I3f}E or if y(na have any questions regarding the fee OF cexempli ns,pleaa'so CAH they BO a, 016,322 90fs9 or t,-r;ul
<br /> to the BOE at tlae i;ho"N ing address Board of Equalization,Fuezl`Faxt,:s Divkion,11,0.Box 942,,79,S,ac,<a,�a�eaa,r,ti'z? c}112'/9,,-acyl,
<br /> V, I'1:'I'I C}t.la �l'IiS("E I ANtwh4 lel, k't7NSlIiII.I"l'Y lsll.iS`T'1311 ES)y1I'I,r,l"FT7 I tJI'ti I'Is"i, t?Ia:CJ 11. `t`c£ 1 ".,,SIS;,,. ..C:"3 it} s:>"7?a €«` }
<br /> OF`I"I°1L!.-3,C l IA1'1''R 16,CIaI-11()P N",A CODE.OF Rait:"al.LA'I IONS,)
<br /> b
<br /> I<ior t 3:y,xa :r�4,ahcx is;as,asa3 ,the owner and/or€a s;raresr,lr n,ectis;g�the Fed cal and Sta€ financial te.Ir.3tas#iliE �,.;,.w a,..,,.�.UST",,cr° >.�c3 by
<br /> ally Fedcr,al ca:Staate sat Bracy as well as noxa--p l aleuni US,I's are exempt from LhIs rccluitarnent.
<br /> VI,LEGAL NOTIFICATION AND 131`1,11Nt ADDRESS '
<br /> Check ONE BO or the:address btai will be used for BOTH t_hCsAI ANT)WILING NOTIFICATIONS_
<br /> TANK OWNI:} C)IZ nil>'t'lIt'lltllt:D REPRESENTATIVE MUSTSIGN AN i7 I A"1'S'
<br /> TI I CtlZ12 A4 L w t',t..x I ilii} i rI;}?.4„C.I k}t' _,7 t
<br /> (a{I3}tJf"1l;`1.IA`?fi`CaT:1T'd'ti}s I6,CALIFORNIA CODE OF} EGULATIONs.}
<br /> INS'IRUC'f2(Jti ItOR_i'lila 1,OCAL AGI:'NC,IIT
<br /> `I`he,county an Jurisdiction manshx s are pr(ci3,teonn)ed and can be Obtained by calling the State i3e,mr'a(9 t£)'227 4303, The Ca i, y r ufntacr nn ay 1v.;
<br /> assign:l lay the,roc l tag Trey;htrw vt r,the s natant( est?sst h rumericaal axaa4 ca.sot cantae <any alph abetit al characucr�', Lt the,l)�,a .ag6nc y p<eefQrs''
<br /> the State Board to assign the facility number,please,leave it blank.
<br /> IT IS"711I;'Rt;,`iitONSIBIL(`l`Y OF TITEs LOCAL ACIENC:Y THAT INSPECTS "I`llE I'A i[:I Y 0 V IIR!!``Y`I1TE ACCURACY OF'1111,
<br /> LNTFO MA`I R)N, TIIIS APPLICATION ION CANNO BE PROCESSED IF THE BBOT:ACCOUNT NUN BEIR IS ISO 14 ,1,1°,D 1N, HE,LOCAL
<br /> AGENCYIS REISPONSIBLE FOR THE CONIPIJ,,TION OF THE "LOCAL AGENCY USE ONLY" INI°`t; I; NTAT'IC3 v 13OX AND FOR
<br /> FORWARDING ONE,FORNI"A"AND ASSOCIATED FORM"B"(s)"I,O THE FOLLOWING ADDR SS, TII1;LOCAL AGENCY SHOT;I D
<br /> RI'TA,N'hill;ORICIS;AI S'A_ND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY"l IIE TANK OWNER, _
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S W,E.E,P S.
<br /> DATA PROCESSINGE'INTI it
<br /> P,O,BOX 527
<br /> Pr1I2AMOL T CA 90723
<br /> T93 g 12081
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