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<br /> i T i FOR
<br /> y y � `d P"'t , 1 "5 Y0 -vi
<br /> GENERAL I�IS"I'FtT✓1 "C'IONS:
<br /> SECTION 2711 OF"T"I"I I ',23,(MATTER 16,CALIFORNIA CODE OF RECL'LA'IION AND Sl?C FIONS 25286,25287,AND 25289 OF C.IIAFTER
<br /> 6M DIVISION 20,CALIFORNIA til ALI'll Ala)SAFETY CODE RE,QI;IRL C WNFRS TO APPLY FOR AN IIS`T'C)TsERA I NO Iil;',AM,A,
<br /> l..One T"'C}I6M"A"shall hc,completed for all NEW P RIND z`C:IIA q S or any FACTLFFYISITE INFORMATION CHANGES.
<br /> S.
<br /> 2 C tt}3NUT ONLY ONE 0)FORLt"A"£or a FacillyTiq regaardleoss caf the rawnb r s,£tasalias located at the site,
<br /> 3. I`hA faun shatdd be owiTletetd by cithhin dac PTwF2MI AP1111CANT or dv,LOCAL AGENCY UNDI_lttaROlj'\D TANK INSPFC"rOR,
<br /> C Please Won ca Pon chzasly au requested i;lEsrmmwn.
<br /> I Use a hard Pam wants d set immen you an m krng x wigsks.
<br /> 6. Tank owmr must submit a facility Plat pian pat can;Inn al agency as Part of the?application shoving the location of the LLIs rs,wing resioactto
<br /> ba ridings arca brimaks[Section 2911 (0EB CCRI,'
<br /> 7. Tank owner +submit documontaf.uii showing ing compliance wida state fiminsial responsibility requironitints'to the local agency as part of a°
<br /> application be pctrolrum USE[Swim 251 OX l,)„CCISI.
<br /> "I'(:3P OF FORXI."MARK ONLY ONE Intl"
<br /> >::`l"
<br /> N4airk an QO in,the box next to the itcan th.aalxl;,at tl s ibes die wasan the forna is being completed,
<br /> L FAC"RI TYfSITE EFORNIA11£) &ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name;and address(physical location)of the underground tank(s).
<br /> NOEL Address`RAT hua e a vAW phys"l'.oc arum aardYA!.'.a1ty,straw,and zip code.
<br /> P,O,BOX NUNIBLISS Aiet<tiC""1"AC.'L�LI£AIIEdIT.
<br /> Include ncemst cress.:.ros Cf Warne;(I Me c£aumtor,
<br /> 2. Phone trunaber must Ina°ze an area crise, If clan,night number is the same,sante"SAME"in pttaper Iaeatit?n,'
<br /> I Checsk we appropriate No fm I`YPC;OF BUS KISS C14`dNERS[Up(ex.C£3R1'C31t.,ATION,INDIVIDUAL,etc.}.
<br /> A Chick A apprvlarbure box Rw TYPE OF BUSINESS.
<br /> 5, H TAT y,Stte is host+d bs An an AdAn mwaaa3m cr othu InTan trust lands,chock the box narked"YES",
<br /> 6, Indicate the itUMMIR of TANKS.at this SII`Li.
<br /> 7, Ilecaxd the ET A.II3 0 car v,ou„h,CJ:'17 in le sraace.Prsavidcd,
<br /> Clonal>..,c all items in this st lbo,wiles,all seems are the same a.SECTION S9 if To samawtim"SANE AS MIT accesss to a.t°ct". Be snare.
<br /> tothccki''it,C7=rLRTYOWNERS!
<br /> ale'S� Ik.l: sax.
<br /> TII.TANK()04`;aER IN Cass`AI10N&.1DD eSS(IsIt ST 311.CONIPLE`IFD)
<br /> ..
<br /> C�e,>aaT}-3c°wall items in t}aes s.� ;t.;€,,a�naessaa.him,at Me same s SECTION t;T9 the sasrtz.,aur€t:.t`:`atCYl€: Aii's.11"a;,sbsah:'ss6c,7;rrza. Be sscc,.
<br /> IS'.BOARD 01-EQUAl_ZATIONUS151AlIAG ali[eACCOUNT NUMBER (MUST HEC",OMIPIAnT1.C).1F,-, <RTICIT5,CElAP], 631 .
<br /> jover your Hold of Tan d i riot=ilia AJ AV..,b.o p ice auca.,.,,<mmba T.'i,,h i . I l'Vnnh,t t liana M wk bc e,�st,t ovd,
<br /> Rc", a 1:h 0,Z WT"0 s_.3..I o that ym ,s :1 r.,-ivc a qua-wily 4 O age Iwo r„t,'n}i, cl f'.1+,do SC,u 3(:>_1Ti31 ) fc-'.,ti,,t on th;,
<br /> I
<br /> (2C)t,ua1 ue€}u lv s?.ia u.;at, .51,e7 f.��z �,� .Lti , ._t.���,. 1 00 „__- ;- '[ e',Cert ...
<br /> .wunas ,,s,. Ala.ta E .. +e.:;.ai y+aa;f5 „, ra.l;ati �-r.., �asa�z.3a,�,�'H & _. re,:itG:
<br /> to h,,34 H a:ox 1 T.,4 .a.a��1_-. ;i.:L A,"ai ns”3 ml Jim 5 UvOs cava,PAs �3ute a, ��.,ut
<br /> _ V, zk.,liZ[yI 1. :l:,.,. d r.a TCM„<'1 z.R3.. ,C)3;S .,.Al'Y{_,z=tea 13s.COMPLIk1Nit 4 zl.Il a.a�i`Yi,,,.°s,�(A!,VY_I _.-
<br /> OF 'nly2 ,CH „ IJI'R IS,CA�I1(', °ZNIyfi.,3.�C`1
<br /> hlrr..`y i. s a; t a.xl, ,tl hy't:.c =no r sst "a3"crAn A r w h.tz,ilve I..c;aa,<c3 i`asap.;.hunWal Y y =.,if a y r., ,.,. ,,,..I >
<br /> any Away to S:Ac as ,oy.a. well as n,rt u-cdcu.,.CSLs it.0 .x_aV6 Th raE.,Mfi. ra
<br /> Ctte k 042a,Ii _Y T .,. .
<br /> yr tA Vii__ ,o all a,N_,ol 4),BO I"II L.T AI,AND"HI-1 I ,NO s ll 1C`A;Itze )
<br /> ., .
<br /> TANK C'is OWNER 011y AI.TlttJ[C/ .a}i,l:PRESENTA IV2 N ST S CS°i A:`tiI?DATE,'.a'111;PORN`AS sM'A „r I.'D, ISIT',Sal HAS in
<br /> Ca} t.?I' F 1111123 C.?iAP IIIR 16,CALIFORNIA COME O3 REGULATIONS]
<br /> T SIRUCTION FOR iSE P LOCAL A(',I,,N.TEs
<br /> Ile cowny at x dwKw,?mmAw are predcts nnit e d and can be ob€aked by calling the sate.Board PHI MTOW. the 3as;is,t nm l v May W
<br /> ara,igna§by d e h.caa aagcnsA;hossov r,this?atunbc< zaaaaat On uw r ricd wid,carzmA catmain any a4kai.€anal claaractcrs, 11 the local at,c.atk.y pm vts
<br /> the S<... Bomd to assia,3 he Baca l t,umbur,Owns leave it blank.
<br /> I`T`IA 1ItE i E SPONSI.3 ._TIT OF HE LOCAL AL AGENCY THAT INSP£iCIS HIP,t ACSL.Ii"Y_10 VEIRIFY THE ACCURACY Y a11r Jim
<br /> INT°ORNIA 1°10 . 1111S A!YLIC7ATION CANNOT BE PROCESSED IF T! BOE ACCOU T INUMEI1N IS NOT PHI ID ib, '1`11I+,i.C3t'Vii;
<br /> '
<br /> AGI-i' C' IS !tESS't.1,s">acIIT FOR THE COMP1,1ITION OF IIIa. LOCAL AGENCY USE ONLY" INI°t1P._LIAIION BOX AND FOR
<br /> I°CtlCas`.<YFC3NNG O F',FORM M"A"AND ASSOCIATED ED FOR 41"130)TO THE FOLLOWING ADDRESS, -IILE LOCAL AGF NC'Y'SHOULD
<br /> lITA,Y 2IIL ORIGINALS AND i'C3RWARL7 THE YELLOW COPIES TOTHE ItC3T.T.OWING ADDRESS.IIIE PINK,COPY S}fi?L;LD BE
<br /> RETAINED BY`111H TANK OWISER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> 00 SNATT'S,
<br /> DATA PROCESSING CENTER
<br /> Y.0?:'-lice 521
<br /> 393
<br /> PARA ;
<br /> ."40 NI',CA 90723
<br /> 'FCJ'i0i24R1
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