|
INSTRURIONS FOR COMPLETING FRM "At"
<br /> CSI I-NERAL INSTRUCTIONS�
<br /> SEC"l"ON'7 11 OYTIT11,23,CHAPTH"R]6,GAJJF-01V,,lAC0DT-OF,!Zl�"('�l�-LATIO-NSAN-DSE-�-ilO\S25286,2,5287,A'�\TD25'ZS9 OF CIIAP'I'FR
<br /> ' ' 4 P
<br /> 63,DIVISION 20,CALIF(Si�NIA I I E'AILTJ I AND SAFHrY CODE R1Cr1?T-`Rl`0WNERST0 Al,'PLY FOR AN UST 011FRA'FING1'1.T T:alrl
<br /> 1, &ne FORM`A-shall yc con)plccod for all MEW PERMITCH,ANGES or any FACII-FT-Y)SITE ENFORNIAIION(,HANGE,&
<br /> 2. SUBMIT ONLY ONE(!)FORM'W'fear z,Facilay/Site,regardless c)f,,h--number of tanks located at the site.
<br /> 3. `Phis form should he cornplmd I)y cither the PE!Qvll'r APP1JCANS'or the LOCAL,AGENCY UNDERGROUND TANKINSPEC7,17OR,
<br /> 4, Please tyle or print cleatly aI oqucSl,,,A
<br /> - Flit— n
<br /> S. Use a hard point writing instruincnz,you arc,making 3 copies.
<br /> 6. Tank owner must submit a facdiiy plot pkin 10 he local agency as part of the ajaplicai ion showuol the location of the USTs with respect to
<br /> buildings and Lmdniarlss[Section 2711 (a)(8),CCRJ
<br /> 7. Tank owner mast.�,ubmit documentation showing compliance with state financial responsibility requirements to the to agency as,part of the
<br /> application for petroleum US` S[Section 2711 (a)(1 1),CC RJ
<br /> TOP OF PORI':"IMARK ON'f,Y ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the foron is being completed,
<br /> I. FACILITY/SI'1'1,'f,sl-'ORNIA'I'ION&ADDRESS(MUSTBECOMPIJ-DED)
<br /> I. Record name and address(physical location)of the orulclground tank(s).
<br /> NOTE: Address MUST have a valid p1hysical location including city,state,and zip Code,
<br /> IWBOX NUMBERS ARI,',,,,o,r ACCI`IYT'ABL,E.
<br /> hicIndc nearest cross street and narne,of the operator.
<br /> 2. Phone number must ha se an area oxie. If the night mirntier is the same,write"SAI 1E"in proper location.
<br /> 3. Check the appropriate tiox for TYPE OFBUSINE'SS OWNEIRSHIP(ex.CORPORATION,INDIVIDUAL,,Cie.),
<br /> 4. Check the appropriate box for TYPE OF fit SINESS.
<br /> 5. check the box marked"YES".
<br /> 6. Indicate,the NU"VIBER,of TANKS at this SITE"
<br /> 7. Record the E.P.A.ID#or write"NOINE"in the space provided.
<br /> 11. IIROI'Il:ltTYOWNt-"RINI-'(.)IZi+,,IAI'IO,',&Al,)I)RILSS(,lt'S'1'131:';COMI'],,E'1-1,,'I))
<br /> Complete all items in this section,nales's,all itcim we the sarne,as'SF(`FI01N 1;If the same.,write"SAME,AS SITE"across this so tion, Ile sure
<br /> to check PROPE.RTY OWNE.RSHIPTYPE tx-)x.
<br /> 1IL TANK OWNER IN1aO104ATION&ADDRII'SS(MUST tai.COMPLETED)
<br /> Complete,all,items in this WCGOTI,unless all items are die Sallie as SFC'IION 1;If the same,write"SAME AS SI'TL"aclosi this,section. Be stare
<br /> to cheek TANK 0INNERSTYPE;box,
<br /> TV.BOARD 01:E"QUALIZATI(YN USTS'l OIWA,1' ACCOUNTNUMBER(MUST 131".CONIPLE'TUD,SEE,AC.'WFICI 11'5,(ATAP-11'R 6,-ml
<br /> DIVISION 2(11,CALIFOPNI's!il1.11 1'I1 AND SAYI iTy CO'DE")
<br /> Hnwy ar Boa;d of Nit`) )TUST stolaye Sec accounr nwnla r vdhich as rcq,aied bcfore yolir jx!nnit q-n &
<br /> �ica�;on can bv pm,�cssc
<br /> wiih thc ll() oill c.ls"Ar'�lffiat-yo�l will n:c, e a marc;poning ihe dkuc n dhe
<br /> to lhc 130a at 6foli,Qb,,jpg B,mul,oflIqL„2Lr,Iion,Ftwl',axe ,)Ms�on,11,0Pox 9-!-N'19f ("A 9
<br /> V. Pl`1TIl()l1l,;'M, U'STHI`<ANCTAI_RFSPONSI 131111 Y('sI( ST BE COVIII,T�IT'D FOR NF']R01.1.=.'51 US]s ON S
<br /> R>MS 2"N I (aVX)
<br /> OFTI'll-F'23,CHAIYTFIt 16.CAIA]FORMA COOH,OFN 1�G(-'!A1'10""5')
<br /> 1JS(,d by Fla o1i;CFcd;1,-,n,and final;6"d.clyonsckik�y S'!
<br /> opclw""',i�
<br /> aily F0dCNN oTS1-,Ac agcn,,y ,,vv,Ij .,:n US Li are eKcTnpt fiOM this
<br /> VI.I-FIGAI.NOTH'ICAIfONANT)HILIAI.N�(,,ADD!�LSS
<br /> Check ONF BOX sor 011,1t v ill bc,i cd for 130]11 LEIGAIL As,D BILLENGNO'!11:1('Wj P,).`,'S,
<br /> TANK OWNER OR A UTI l0k jZ FD RJ�,i'k ESI'N'!ATI VE,MUSTSRI NAM)l
<br /> (a)(13)01,T111,1`23 CII Ala[Ails !6,CAIJIORNIA Co ,)I"IC)1,all,(;L11-,A'Ilt)',\'s
<br /> INSTRUCTION FOR'1111,1'l,()CAl, (;1'1.\(.H',1S
<br /> The county an
<br /> MAI alt nw','(�a pTcdctem-'unc,",and beobtairwd b,, S%itc.3,a; (910)22"? 43(131 ]F1,
<br /> assigned by nae ho%v,,,v�r, mimbecruast b",ria-nc6c�a;,w'd cal,'MA Ccmla.n any thc
<br /> the Slate Boal d'o as4;o u'lc 1,161y plea;e k,,avei-I blank,
<br /> IT IS 'I HE R'1:`>:-,CNSI'�)",,"
<br /> T�!)CA�, Al,-U7,,NCY THAT IN"SPFC! TO VF, �!Y Tflk ACCM�,ACY OF'1111,'
<br /> I-NF()RMAT-Y,,N. I il,'S A`P�ZJCAI IoN iNTN""N"iW-I'R;"S Nof 11", �J,E 1,1 iNft, �LOCAI�
<br /> AGI,NCY Isc+3 OR TljI'
<br /> OF " 1A),CA( AGFN( 1Kct a !Ni,W`IIATION BOX A,11;D FOR
<br /> 111F `011�1,OWING Al"W16ESS, TNIL 1,C)CAL,AG'E-NCY SHOU[J)
<br /> FORWA it 1)TN0 ONE J,OJRN1,A' ANJD ASSOCIA1,L"D V0111,141,11-lks)I N
<br /> '
<br /> LLOW 's TCI'Also 1-01-1.0WING ADDRE'SS,THE PINK COPY SHOUI.D BF
<br /> REJAINTHi`WJCINAI�S AND FORWARDTHE'YF.,, COPIET
<br /> R l,l"I'A T NE 1)B YJ I i E'FANK OWN ER
<br /> FOR012ORI
<br />
|