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<br />INSTRUrCTIONS FOR COMPLETING FORM '"'Apt
<br />GENERAL iNSTRIJCTIONS:
<br />;l,'C:`I','O'\ 2"711 f)T° "T 1 S Li 2:', C.i;. I'"z.:R 16, CAI.I,FORNIA CODE OF RF. GULATIC N3 AND SECTIONS 25286,25287, AND 25289 OF CHAPTER
<br />i.7, DIVISiCt'ti ?iY,,CAI.tIr(.}IZ\'Irk IITIALTII Ar NI SAi;I i"Y £:ODI-.' ;EQ IR.k,:3WNERS' IO API"I,Y F -OR AN I S'I OIII I�AI T-NIC°a 1 L,',R, 11'r.
<br />L One Tr(:iRM "A" shall be completed for all NEW PER-NAIT C~Fir'tNGES car any F AC1I ITYISITFT ia�Ts'OI2?v1A71ON CHANGES,
<br />2. S MMIT ONLY ONE (1) FORM "A" Por a FacilityfSitc, reg;anfless of the number of'tanks located at the site.
<br />3. This form should be completed by eithar the Pl RMrr APPLICANT` or the LOCAL AGONCY iSI 9E.R.GROUND TANK INSPfiC"I`il&
<br />4. Please typo or prink cltttuly all, rcyuestc al information.
<br />S" Use a hard point writing instrument, yqu art; ming 3 -copies,
<br />Ct. Tank owner must submit. a M4:dlity ploi plant to the local. agency &&part of the application` showing the location of the U! I'a withlrespect to `
<br />buildings and landmark:: [Section 2711 (a)(8), CCRJ,
<br />7."Tank ` twner must suba it documentation showing complian e with state financial responsibility ui cpf w t WAO local'a ency as. apt the
<br />application for petrolcurn I, S'1"s [Section 2711 (a)(1 I), CCRJ. t
<br />"iI`OPOFF<IiCt :`a iAR C)NLV 'ON F: iI'I?M
<br />Mails an (X) in the box next to the item that bett,describes thereason the form iz being completed ;
<br />I: FACII.'tl`Y/Sl'i'4° 1VFO3RYM 'i-1 )N & :;1}IiRFSS M S axa.,":4';a?,1fa1..S;1'ED)
<br />13:_a..-tna ct,;Ile .:i.€. 1 nk
<br />u.
<br />y ,.
<br />'�Ci
<br />OTE,,: A,Idr„sa SIvS a have r, : ,i,S ph, . _ x.n=,:_,aca;y, statc, and zip code.
<br />I c1t. is nearest rsrss sere, f and n Eric; of the t;rator.
<br />2. 2l th night number is the same, write "SAIME" its properlocation,
<br />3. Check the appropriate Erox for TYPh" OF BUSItNI'SS OWNERSTIIi' (ex- CORPORATION, INCDIV"IIiUAL.; etc.).
<br />4. Chuck the appropriate box for TYT'l OF BUSINESS.
<br />5, If I ac slat} `5itc is Inca€ed within an IDdian reservation or other Indian trust lands, check the bzix mssrktd "YES" t
<br />6. Indicate the N 1SMBER ofTANKS at this SITE
<br />7. _Record the E,P.A. ID # or write `NONE" in title space provided.
<br />]I. PROPERTY OWNER INIr£ RNIATION & ADDRESS ( Ii. ST BE COMPLETED)
<br />Complete all items in this scctiorl„ unless ail items are the same as SECTION 1; If the same, write "SAME, AS SS I"ii" aerass,this sea€tlom Ile surd
<br />to claac3c L'.ltC)I'i`s.ILTY CyVdSvrh:RSIi1S' TYk'I's'box,
<br />r 4..
<br />TIT. TANK OWNER R IN1'C)RMATION & ADDRI S`s (MUST I3p "tJ'tr9l'I. E T`ED)
<br />Complete all iterns in this seat ion,, a ales act ilunns are the same as SECTION I, if the'same, wriie;,S kM1 E, AS i a S;"Be stir'--
<br />to chcx.[c "E`rtNk. (3WNEItS I`YIT Cox,
<br />I'V,, BOARD OI- T'()CAi_-e;A 1I'(JN F t ,.I ACbwl?CiNT NUMB .'R c II1S`i 13E COMl'LE-1TM" Sl -FE' ARTICLE 5, i;`-r'I'12'(-7 '
<br />DIVISION 2t),CALIFORNIA 11EAI.I`II ANI) SAFETY C01:)E.)
<br />Fnwrvour B'oa.d of 1,,: li..,h la.0 (110E) _ . i sto-at w ac_olult number wlic:h ,s reepitired I rfore, y.a,.tr lx'rnit a €.rit� lion .', 1"'l" MAX, 'Xf.
<br />c" BOF x r iie a (jiamerly st age l e retn.'Tv in re p« rt rad t'i ,>i) i` i r ;' E due on i it
<br />umb
<br />r<># 1,;-,, t- r3z<z. W�=r.. yi)<.r .. ._. ?,-. sC-P<t, cock jx Sons e,xtrt,r,t frena rsy�in" th
<br />hl'ly , all .ac..:x;.,-tt t,. mIx.r yr ith nOl'o Iasi:, or if you have any yue stlo is rel,ardtng the tec of uv nption a7r ,tsc: c,i11 .,,w l;ti'." a i:ti 321" 9009 r, , , role,
<br />ts> tlte, .3t?l: r,t ti, fulls, rEtp a �.t., 3c;�i:<s ! la ua E.asti�il, I uci 'Bares llivision, 1'.£7.
<br />V, PI""'ITCtLEI"'M t,"S1 NNA.NCiALRI:'Si'C)NSIBILITY (MR-``y'f BE CC'3MPIA,IIwi` FOR ;_, !"N': ,rl....> #i
<br />(JFa3I7t. :.I1AP12 R 16,C;AI,Iti}.£NIA ,ODEO RI,WI LA'1St,?J`S,)
<br />ldc;r t,.y ;h' ii c'lhn_(S) ll' Cd by fl-- ov'n—, singior op.,a .r, it-, i 3co'61fg the , e"k"ral and State financial 0"'p xsi' i -ty
<br />any = cv,c°ital cin St.a€c ap,crac,; as tr t,i w_ F.:S"ls ar= t;xeiitipt from t17.a iesiuttc s;exif.
<br />VLLEGAL NOTIFiCA1"ONA'NDBILLING ADDRESS :l
<br />Check. O'NE BOX fe:r tlic ,ai dil"ss 0 at - ipf be used for 13C3111 1,EGAL AND BILLING Nt7TFIC:A'T R-YyS,
<br />TANK OWNER OR A(: I'l lORIZE' 7 PEPRES1.N 1 A1IVl: MLS 1' SIGN AND DA 11, "S Ills FORNI AS IN'D,C"A 1 `1 , , ..i: .,C E it>'`S 1 i
<br />(a)(I3) OF 'T I"I`LE. 23 ClIA1'"1'ER 16, C'AL"I'C1RNIA CODE, OF R'EC.1C ,A`I`IONS.]
<br />iNS'IiZUC"tION F ORlIE' LOCA 1, AC,LNC IFS
<br />'1`hc c.,ana; a a_i. iz:>t!'ctie at rlurn x.r- are can i3c of>ttairieei byr calling the State l3z>arri t9I6t2274303. 1t.- Fa., -:,tai r ra,Gy Ira
<br />asst rt.xl
<br />by the lo'u.il a, .i -"y; ho.a .:c r,',h.'number must lso nurn meal and carwwt cont.ana any alp habe6cal cb arwcners, It .c lc.2it a caa�y Irr�a.ers
<br />the State llo:ud to a si t tho fa cizfy number, please leave, it blank,
<br />I7• IS '1111,"RlaSPONSIBIL TY OF T11131 LOCAL AGENCY Y THAT INSPECTS "1'HE FACILITY "It) VERIFY Ta,Is ACCURACY OF 't`CTE
<br />INFORMATION. `I'IIIS APPi_IC'ATION' CANNOT` BE PROCESSED IF TIIE I3OE AC OUNTS� Nii1113ER IS N0'1' 1,I1.LT3F� IN, 'IITT Fb LOCAL
<br />A(;sI.tiCY IS RESPONSIBLE F, C£)
<br />FOR T11MT'Ll,, `ION OF THE "LOCAL AGENCY USE ONLY" ". INFORMATION BOX AND FOR
<br />FORWARDING ONE FORM"A" AND ASSOCIATED FORM °i3'(s) TO TTIE FOLLOWING Al DRR'SS. THE LOCAL AGENCY SHOU'Ll)
<br />RETAI`e ` 11F' OR1GD Ai.s` AND € ORWARD THE ELLOW COPIES TO THE F OLI.C3i I6'NG DDRESS, "THE PINK. COPY SHOULDIii:
<br />RETAINED TAINT. D BY °I"HF TANK OWNER.
<br />STATL OF CALIFORNIA
<br />r
<br />STA'I'E "WATER RESOURCES CONTROL 130ARD
<br />C/0 &, ,V,E.P, ,
<br />DATA PROCESSIaNCT CENS'i3it
<br />P.0, 13OX 527
<br />PARAMOUNT, I', CA. 90723
<br />X33
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