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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF RI:,GUI,ATIONS AND SECTIONS p.i`§2y5,�286,255287,AND 25281)OF CHAPIT,,R
<br /> 6.7,DIVISION 20,CALIFORNIA HEA1."111 AND SAFI�.TY CODE Rl-' 3Q ;IRE O'VVNERS TO APPLY FOR."AUS1"OPERA7`1NG PERMIT.
<br /> L One FORM°'A"sh311 be completed:for all NEW PE Rte I T'CHANGE,S or arty F AC.ILT"I`Y/Sl l'l-,L FOI3 \4ATION CHANGES.
<br /> 2, SUBMITONLY ONE(1)FORM"A"for a Fac€lityl'Site,regardless of the rumbcr of tanks located at the site,
<br /> 3. This form should be coinpleted by either die PERAMIT APPLICANT orthe l-CAL AGENCY U:*'l ERGROUNl)TANK INSPECTOR,
<br /> 4, Please type or print clearly all requested infonnation.
<br /> 5, Use a hard point writing instrument,you are making;3 copies.
<br /> 6, Tank owner mun 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 landmarks[Section 2711(a)(8),CCRJ,
<br /> 7. Tank owner crust submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(11),C:CRJ,
<br /> TOP OF FORME:"MARK ONLY ONE,ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed,
<br /> 1. FACILITYISrFE INFORMATION&AI3DRES`'s(kIUST BE C:ONIP1.E11D)
<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 code,
<br /> P.O.BOX Nt;1V113ERS ARE NOT ACCEP'PABLE,
<br /> Include nearest cross s€.reet and name of the ops,rator.
<br /> 2. Phone number rruxst have;an area rode. 1f"ine,night niunbe.r is the same,write"SANIEI"in proper location.
<br /> 3. Check trhe approp€late hex.for TYPL OF BUSI.NIHISS ONVIN:RSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropii.aw bo,for TYPE OF'BUSTEN1 s5,
<br /> 5. 1.f l a�.i at,Sire is Icx at u a F=t n It'Jiarr r4. . ati<ur or ether htc3ian trust bids,check the box marked"YES".
<br /> G. lndicaw,the NU1413,'E' of TANKS at.this S11
<br /> 7. Record the EJI,A.11)€+or write'NOtiE."in the spa e piovided,
<br /> 11. PROM-iR l'Y OWIN R I.N FORM31�"�ATION&ADDRESS ESS �`I s'1'1 E COiV FLET 31))
<br /> Corrpletc ali items in thi<-se'abort,unlc ss all iter^s are die saint,as SSl%E.',"I`ION 1;if the sanic,write"SAME AS Sr l'E"across this sect on, I've.sure
<br /> to check PROPERTY OWIN-1:16111I'I'YE3C lx;x.
<br /> 11i.`I:ANK OWNT"R INFORMA'1'ON&ADDRESS(:4'lr.1ST 1a E's CONIPLETI-J))
<br /> Complc;e all ittnras in this stoic.t,ualss all items are thesanr'e as SEC'ION 1;'If the same,write"SAME AS SITE"across tlais'sccticrt. Be sure
<br /> to cheek z r"NK OWNS.2S TYNF box.
<br /> IV,I3C),'tRD OF 1t:C,1t,AT_IZA;.ON UIST STORA F FE.'F AC C01.;\T:bt,`F BI*.iIC(NIUST BE,CC)4IPLETED,Sf,'X ARTIa.E 5,C'JTAP1 z'R&75,
<br /> T)IV1S,O",'2t;,CALIFOR A lil.aALI'EI ANP,SMFF,;' C0 l,,)
<br /> A,—!91,,,;3.. 'f,69
<br /> or v"i.e
<br /> to tT e 13011: t,e.r,1.[c a>.., dies_Board,)4 1 q:.:,sra t;r,,Fwd TaAcs r,rpt:u;d.,z',4 3,a:`., M22?. g,`lad ramewrt ,CA 9-112 =i.
<br /> V, 1'li"1FZ(,I_l, l U'S.` F1 ANC,I L. .lii't);SIBII..n Y C:OMPIJa TEM i 01k l' l TQC?,..,UMI US'T.,ONLY,S1 E l.,'S14 FiONS 271 (a)(8)
<br /> OF"b:'_:,F 23,CHAI'1 ER 16,C A . ORM,h COIR,.,OF 1,EL°sULATIOINS.)
<br /> Tcic:r;afy iiu;n etf;cxl(si,:,;x1 I,y ire o r:c.r aat'c;r operator,i€t rrtcttti;t�„t,c T cderaT and sate ftns:;c<al tf'sponsa-b_rtj r Qui?.E_v,..c.UISTs= vix,d by
<br /> arra'T cdui l aai.or`Tat€;agency as:cell as ni>nrlxFrzii unr UST's s art;exempt.front this rcr utrcrnntu,
<br /> '6r,LEGAL ()l lt:tC :ION AND B11-LING'A€) ,f ESS
<br /> Che;i 0M:u(1x l:?t t.., ;Id,.,, fl:at v.,.11 b" E s-z.d for 1.30 111 LEGAL AND tgrLIXNG tt}
<br /> TANK t:)1lNER 0;
<br /> (a)(13)("I "i- i 111'23(IIAil ilu Z 16,CAL IL ORNJA CODE OF RFCat t<t;"3"Tr:1`S j
<br /> INSIRCCTIkO v aFOR',-111F.' L ACU"N(.11:,S
<br /> Tile cu::
<br /> nty an F,.,:,ui:,,:a,na.ua r,a%�pt zmd can be oNainedby calling;tI<c&tutu B(xird 016)2-17430.3, "t i;c's'ut l€ r nu nborrnay tx.
<br /> assigned by the local } :�nzy;tzoti,.z c.s„:his number nlusEbe and cannot centaur ainy;alpha.,t;�:ui If the k-,ca[agcnt y prefr:rs
<br /> the.State I.3oard to assif,cr Lie fa hits;zit:,;i;<:r,please lea%ve,,it hl,"ik,
<br /> AI _1i,., 1'7IA'1 F ; I'1:C. I 'lEH FACILI 1Y TO 4'RIFY THE ACCURACY OF THE
<br /> IN O[,N.. z;()N- T1i,S.i,PLI 't t VIN CANN:.l BE.i;;t 1C. .i:T)IE '1Ili,1§OE<°;((Ol.'NT Nt_'NME R IS NOT 1'11 LIii)IN, "III 1.,()CAL
<br /> _ 10XAGI,'NCY IS 1;. P Nx311FOR CO,%1 A--1 N O llF 'LOCAL � ,;lNC USE � PAND FOR
<br /> Ft)11%'.A RD'\G,ONt� t, }:a`>' y AND ASS(1)C� A 11=i3 ItC)RNI"B`&'`hO Tlll�',Ft'3;.1_t:}4ti'CrNG ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RF;,Apar"1IEF,OR GIN.at_S AND FORWARD TIT . YEILLOW COPIT,S TO°IIIE FOLLC31 L\G ADDRESS,THE PINK COPY SHOULD BE
<br /> REI AINED BVI IIE TANK OWNER,
<br /> 3x33 FOR012ORI
<br /> 1,
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