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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> T.C.,I'IC.1.e 271101 TI IA"23,Cl 16,C"A11FO NIA CODE OF REC;UI AT"IONS AND SECTIONS 25286,255287,AND 25289 OF CHAPTLR
<br /> 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST C3I`'Ia.S2r1.2`ING PERMIT,
<br /> 1 m ;
<br /> 1. OneI°f)TC bl"A"shall Ue cissn Teted far alI!E; t lsI ERMIT CHANGES or any 1 ACIT IT Y1SIT E ITbF'tyF��lA`FfICyNI CHANGES,
<br /> 2, SliBaVtIT ONLY ONE(I)Ir()T2.M"A"for a FacilitylSitc%regardless of the number of tanks located at the site,
<br /> 1 This fonts should be co npleted by either the i'1>RMIT,'P111,1C AN'T'est the LOCAL AGENCY UNDI itr.:IaOUND TANK INS111 C"TOR
<br /> 4. Please typo or print clearly all requested information.
<br /> S. Use a'hard point writing instrument,you are snaking 3 copies,
<br /> 6.Tank owner roust submit a facility plot plan to the Neal agency as part of the applications showing the location of the USTs with'rnspect to
<br /> buildings and landmarks[Section 2711(a)(8),CCRJ.
<br /> 7, Tank owner must submit documentation st owing compliance with state financial responsibility requirements to the local agency as part r f the
<br /> application for,Petroleum UST's[Section 2715(a)(11),CCRJ,
<br /> OP OF FOR%4� "MARK ONLY ONE,ITEM"
<br /> Nark an(X)in the box next to the ueni that lx, t descriPses the reason the forint is being complete
<br /> L FAC ILITY/S11`.,,LNIeORIMA]ION&ADDRESS(MUST BE C:CJNIPL TED)
<br /> 1. Record name and address(physical location)of the underground tanks).
<br /> NOTE,: Address NIUSST have as valid physical location including city,state,and zip code.
<br /> 11,0.13C)A'aC?14°tBERS ARE,N01 ACCEPTABLE.
<br /> Include nearestcrass street and narsne of the operator,
<br /> 2. Phone number must have an area code, If the night nurnber is the sante,write"SAME"in proper location.
<br /> 3bCheck the,appropr'sate Fxsx for TYPE,OF BUSINESS SS OiVNE,RSHIP(ex.CORPORATION,INDIVIDUAL,;etc.),
<br /> 4. Check the apprupiiatc box for TYPE OF BUSINESS.
<br /> 5, If Fac ilityiSite is located within an Indianreser atlsxt or other Indian trust lands,check the box marked"YES",
<br /> 6.Iru3ac.ate the NUMBER BER of TANKS at this SIT l-
<br /> 7, R.ecoid the I.I',A.11?.#or-write NONE"ars the splice provided.
<br /> C omplete all ittans in this seC6011,un'ess,all heti€s arc the same as SFEC'I10N I;If the same,write"SAME,AS SITE"across this wmioa. Be sure
<br /> to check PROPERTY OWN I RSI 11P'Illi f,box.
<br /> III.TANK OWNER INIrC)RMATI(.DIti&AI>DR SS(MIDSTBE,COMPLETED)
<br /> compleic all nein:ih'thiS sectiosn,aztilass all items,are the same asSECTION l;If the sarne,write"SAME AS Ss H".across dais section. Ile;Sure
<br /> to check TANK O'tr NE-'RS T'I P1,,,box.
<br /> I&`,BOARD OF Iz(aiL, IJZA"5IO 145;S" 0RA(',[,FEE ACCOUNT Nt;MBE.R(NIUST BE C:OMPLE'lF,D.SC;Ti°ACI l"CLE 5,C°IIAI'"I'I'.R 035,
<br /> DIVISION 2f),C.ALIl OIC IA HEALTH,<1:ND 4.,,E Y(:ODE,,)
<br /> tinter vout Bord orf"E'qua�ra�ion(B(Ai)UST storage sec account nu berwhich is required ,foo your fern it a}plic<afion,.an tri.i r..,csSed.
<br /> ICegt�z=.:ntic>n tater ih B01"iii! r_ss t ;ae 11 rt eive a quarterly stcsrage fee.return in repo€ting the SOAM ((.rit;l ,t� ;_ .�Fsr.fct w or c
<br /> number-ofgal,t.� y°vuE _sl"s. code lx;€sons:exctnpt boon,p,tlfing the aWMg fie arc;r.Iun,,viii �.,c,.;_� .inns. li 'tit a Tc t
<br /> mate an raccoli_tt alarrlrc r o:a°In trtc BOE or i1 you soave any questions regarding the fee or=ek..r nsis�tii ,pleas-call dic afO..,a, 116�V-12 9661)or ,vile
<br /> to sire BOE,<atthe fe;It;rrx.Eaiy,add .sg I3oa,rd of Fuel Taxes Division,I'.C3.BUM s422€79,4<scrarrtcrt!E.,C:A'v12" ,.,C;'z.
<br /> V. PE I1C:ILEUM C,S I l-IN 1,RC;IAL lUt Sl1C7,NSIIITI"1`I'y(Ml'S"I'111i CX NIPLETED FOR I'IuTR0l,Ia.'M l SI's ONLY,SEE SF(i:IONS 27f; 6)0( )'
<br /> 16,CALIFORNIA(,'ODI ,OF REGiULA"I IONS,):.
<br /> IdCuti?y the rt€c 010i1(a)Wed by the owner and/or opor ,tor,in meeting the 1`edcral and State financial tcsponsibih€y reCi Jt2,11 .i1`,US"i S ov ncA by
<br /> any I�cdmd car Staw agency as well as non pcuolcum I.STs are excnlpt from this t€x"uhcrncm,
<br /> VI.I.I:C ALNOT11nlC.".ATION rAND BILLING ADDRESS
<br /> Check ON['BON for thc addeas l olt W�H be a ed for Il£`)°I'll LEGAL AND BILLING N€s'I`JFIC1"i V)�, ,
<br /> TANK OWNER,4:(Z AU'llI(,)RIZE'1 hI;€',Zf. I N 1< 114'aa MUSl'SIGN AND D F TII[-,F0 M AS I`'>DIC (.eta. !s _i`, <,t.r1,1'-)NS 711
<br /> (a)(13)O TI I Lt: 3 r H AI'f LR 16,C CLAIM NIA CODE OF RE'( ULA I IO S.1
<br /> P\S'lR1JCI'ION FOR 1111E LOCAL AGENCIES
<br /> The county an jurisdiction to tA:at a(;c,s are hr, a;uentlined and can be obtained by calling the State Roard(9,16)227-4301 i,.c
<br /> assigned by ttu�local ag.rncy;ho�asvcr,this w anbe;r;oust be nurtnesic;:l and canmrt continua any aalpnabetic;tl!characters. If the local,agc?wy prefer."
<br /> the State Board to assign the faciiJty number,please,leave it blank.
<br /> IT IS`I III:`IZI:SI'ONSII31LJTY OFTHE' LOCAL AGENCY THAT INSPECIS,THE FACILITY `I0 VERIFY THE AC(.t.IRACY OF`I CTI:
<br /> INFORMATION. THIS APPLICATION ION C'ANNO I I3k PROC ESSED IF THE BOE',ACC:OIJN I'NU.N1I3ER IS NOT T II,LF B TN. THE.LocAT.
<br /> AGENCY ;IS RJESPONSi(II.E FORilHE C°ONIJ'I<I,fION OF THE "LOCAL AGENCY USE ONLY" INI�ORNMATIO BOX AND FOR
<br /> I'ClRW AI,,a..N(,ONE FORM`A'AND ASSOCIATED I`ORIM"F3"(s) TO t`1i1,I'C3I..tdC}WLNG ADDR:F':S4, THE"l»OCAL x'4C,E C:Y°S(Oill.T)
<br /> RETAIN Tl Ill C RK"WINAI S XND I`O W'ARD TI IE YELLOW COPIES TO TIIF FOLLOWING ADDRESS.THE PINK.COPY SHOULD BE
<br /> RE-FAINED BYI HE,TANK OWNER.
<br /> STATE'OF CALIFORNIA
<br /> STATE WAT E.R.RESOUR(.ES CONTROL BOARD
<br /> C/O S,W'.h.F.P.S,
<br /> DATA P OCESSLNGCENTER
<br /> P.0,BOX 527
<br /> PARAMOUNT,CA 907723
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<br /> FOP412ORI
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