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INSTRUCTIONS" lr
<br />GENERAL INSTRUCTIONS:
<br />RUCTION
<br />SECTION 2711 OF `i ITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25289 OF CHAPTER
<br />6.7; DIVISION -40, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE € WNERS 1.0 APPLY FOR AN UST OPERATING PERMIT.
<br />I. One FORM "A" shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br />2, SUBMIT ONLY ONE (1) FORM „A" fora Facility/Site, regardless of the number of tanks located at the site,
<br />1 This forts should be completed by either the, PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. Please type or print clearly all requested 'information.
<br />5, Use a hard point writing instrusalent, you are making 3 copies.
<br />6. Tank owner must submit a facility plot plan teethe local agency as part of the application showing the location of the USTswithrespect iia -
<br />buildings:and landmarks [Section' -1711 (a)(8), CCR].
<br />7. Tank fawner must submit docurn nt<ation showini, compliance with state financial responsibility requirements to the local agency as part ofthe
<br />application for pet, mleurn t,'S'T">, (Section 2711 (z)(I I), CCR],
<br />TOP OF FORM° `MARK ONLY ONE ITF,yI„
<br />Mark. an ON in the box next to the item that best descBbes the reason the form is being completed.
<br />L FACILITY/SITE, INFORMATION:-- A60RI SS (Clu5'T BECt NIPI F TTD)
<br />I. Record nasaae and address (physical loeaBon} of the underground tank(s).
<br />NOTE: Address MUST have a valid physical location n including city, state,. and rip code.
<br />RO, BOX NU3]y'IBFRS ARE NOT ACCEPTABLE,
<br />Include nearest crass 5tre t and rias .e of the operator.
<br />2. Phone number roust have ars area code, ,f al na i;t rcr. rf ,.a i_ ila< �a„su< w.:3ts ” �L Bis sn proper is anon.
<br />3. Check the ,appropriat=e box f, -)r TY = E OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.),
<br />4. Check the appropriate box for TYPE'OF BUSINESS.
<br />5. If Facilely/;ire is recited at€Iris, a i ,elan .�., n.°idose eT other Indra trust iandc, check the box marked "`IES".
<br />6, indicate the NUMBER nr CANKI is S1. FE,
<br />T Record the E.P.A. ID #sir -wrile "N . NIE, ,., e e stelae provided.
<br />II. PROPERTY OWNER INFORMATION ADDRESS (MUST BE CC?,`,,1P E` L3)
<br />Complained items in th s st ction, unless all items, 3a, r afar sat.at ;ab SECTION l; If £he sante, write: "SAME AS SITE" across this section, Be sure:
<br />to check PROPERTY OWNERSHIP TYT;
<br />ill. TANK OWNER INFORMATION & ADl)R SS (MOST BF. C OMPL ETED)
<br />Cornplete all iterns in thin , se rW60e, ti,n,:r„ -L11 itCnAS urC ubu Satre ,,s SECTION ION 1r if the s<am , write "SAME AS SITE" across this section. Be -sure
<br />to check TANK OWNERS TYPE box,
<br />TV. BOARD OF EQUAI. K,A ION UST `> ORAGE FEE. ACCOUNT NUMBER MBER l,M ST BE COMPLETED, SISI, ARTICLE 5, CHAPTER 6.75,
<br />DIVISION 20, CALIF
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