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Ib S . i lS COMPLErING F(*,l ""A" ,•
<br /> t:ENER L INSTRUCTIONS:
<br /> 2711 OFTITLE E 23,CHAPTER Ili,CALIFORNIA CODE OF REGULATION'S ANDSEC11ONS 2529 ,252,97,XND 2,5289 CSI" IIA TT'R
<br /> 6.71 DIVISION 20,CALIFORNIA 13I AZ Fll rA D SAFETY COD REQUTI£E OWNERS TO APPLY FOR AN UST OPERATING PI,,RmI
<br /> 1, One FORM"A`shall Ix cornplct°cd for all'v EAS PERTMIT CHANCES or any F CIL`I'Yf`a`ITr INFoRMAIION CHANGES,
<br /> 2.`SUB II ONLY ONE(t)FORL1°'A>'fora Facility/Site,regardless of the number of ranks located at the site,
<br /> 3, This fo,.n sb,:urld be completed byialcr.the PERN41TAPP11C"ANT or the,LOCAL AGEINCY UNDERGROUND TANK INSTIan't)R,
<br /> 4. Plaayse tyfx,,or,print clfta ly ail acgrfe tz*.d int'om-radon,
<br /> 5. Use a ha.ril p(ala,writing iitxmnnent,you arc naa€ing;3 colti:.s,
<br /> 6. Tank owner rnua t subs—nit a facility plot pian to the local agency as part of the application showing,the location of the UST s with rospect to
<br /> buildings and Tai 3.-,narks[Section 2711 (a)(8),CC I,
<br /> 7. Tank owner ria.. _submit docurnentation showing compliance want state finaticfalresponsibility raquireon tats to the local agency as hart of w3iss`
<br /> application for petr€alcum USTs[Sc�tion 2711(a)(l l),CC RJ,
<br /> TOPOFFORNI:".kl ARK ONLY ONE 111-1
<br /> Markrarr(X)in the box next to the itcris th:;t beat cl scrfbas t1he reason the;form is being completed,
<br /> I. FACILITY/SITEFACILITY/SITE i NFORMA iZtJN dx ADDRESS(MUST RE C€MPLEI ED)
<br /> I. Record narne and address(physical,Imaarion)of the underground tahk(s),
<br /> NOTE: Address NIUST have a valid physical?ts:ation including city,state,and zip coder,
<br /> P.C),BOX rNUNIBERS ARE NOT ACCE11TABL .
<br /> lnc,wie nearest Cress street red narnt;of the S
<br /> og�crator:
<br /> . .
<br /> 2. Sora nxarr?trer mus,have atz azaa coda. If tne high',number is the seine,aerate" AAII:"in pr?aper Iticaticsrs.
<br /> 3. Chock the appropriate,box for'1`YPI"OF B1,SlN1,'SS OW'.°mERSHIP(rx..CORPORATION,I151VI:DUA ,cof.),
<br /> 4. Chc k alae t,ppropiiaatc box?or TYPE".OF f3L.rs1"AE?,SS,
<br /> 5,,If Fa€c,r,;,Srtr is to a.od wiihin ay"India?n reservation ur oth r tardiarr treat lands,check the box masked YES".
<br /> 6...IncUcate dre NU r,BER ofTANKS a y-his;-"tii"I`F, ,.
<br /> =7, Rc",ird the.ETI A,ID#t or vrrim"NNONI,-in the space provided.
<br /> 11, IaFtC3PERT C)1`f,'F': LN1rCa,'MATI N&ADDI?ESS(MUS"I`I:IId'COMPL,L:TED),
<br /> Cortnpl,;te all i,crns an t~at.s sr cfaoza,tzn.c ss all r cisrs ata to same,as sk;C3`f€)N€�If t:ac,°s?ratiar,as.rtt S >A.a..AS SITE", tat:_ s this ac ctz.-,sa, Be'JaMll
<br /> to check PROPERTY OW'N'1'11RS if PTY111'I'box
<br /> 3Ii. 1`A K£lA' N1,Z,l l>O 'ti ATI a:�;A .�1.'3DRAE S(s L': I Sx C f3yl 1.1.1'FI,
<br /> ,,, eft i,ufow�s aril acct aae the aeine as SECTION 1;If the as ,a fnne,s 6le-,"'A E iV`�
<br /> £;orrr}-1�tc ansli,.s in tpd _. ac.i rs 03s Be 3
<br /> r_
<br /> To€:hack ,'Ass K OWNERSTYPE box.
<br /> IA'.I`I(1t1?l:(#a l3£i r IM:: , 'I`Itt ;.5"1 5it:)1;1<. s C,t>`) `I`SL 1?3a.1Z t .h. t`(ili t t)11lTI.l.1`7:0,4'..E A;,..t`LE 5,i'STAP dal:6>753,
<br /> Ifes y nar Boa d i i i'cl.a{.,..atr.,r.01-1010")
<br /> e r„r,�m _.>C.t. .�,:>-n t1.1 r i di on .,sF z,.i=the;
<br /> eras,, r. ._ l ,c rs._.w 11 ,! l ;Is,
<br /> hav^,m ort..,,,
<br /> V !'ETROi.a.,.Si�,:S”:Il Ay,a IAt.,Rf};tiSl,i:a.il`Ys a.. `i"`1sh<� �xl:.l.lfa 1£y< l'a: l3t)cL(�Al l"Sl' ONLY,
<br /> CT.i.'1'IiCs10,C.ci_.',t),Z !<'ACf.ix.)T3C3I It.,Cr't%=hAIE#;r S.)
<br /> Id rir;,y th;;,: t ro;d,.,)r (!d by rinc t weer and/ca cit`€,rat- r,in melfling the l c il,�ral a„d State ncgict. Ik t::;,a,<r. -crx=s:t x, =n.,.a
<br /> ,
<br /> -nv1 w,€,.Fal S,a"c age *as myo„a.,rein LSTs we cxcanpr Porn this r.,zi t,icrucs r. _
<br /> VL LEGAL HEEDIFIC`ATIO AN!)Fs'I LING fADDIUrSS
<br /> Ctrs::>.e ON!"BOX fondle addr...s tha"t'iiI housed for BOTH LEGAL
<br /> TANK Ok? :Nt.1Z OR AUTI10 2zllr.()REPRESEINTATIVS k1k ST SIG O AND I7ATE,,`.1111"rC)IC'(1 AS INDK' ED, xtl,I..,a:,< €i=r,,<"2`111
<br /> (a)(13)OF Tl t IT,'23 CHAPTER 16,CA€,IFORNIA CODE,Or REGWILATTON a".}
<br /> IIAS"klstiC 1TiJ lrf:3t >ta I:CA( AI:AGENCIES
<br /> The counly an,ysrrsdictioan nu,,rlx.rs are py-ct ocrinhe d a nd can he obtained by calling the State l3yaud Ct11C)227 I��3: T f. r ,.,iiE .ia.nh. ,,r r ay� 74
<br /> assigned k y,;ho local sageficy,lacza ver,this number must to nytineris al and cannot co ntain any alphfila6u;al characters, t}.e B xn<al oaf a,ttG:.y,rar:Etre
<br /> the Stale Board of assign Elie faCiiity cLurnbar,please leave it blank,
<br /> TT`is III:I: I'll E PO SIByLIl`Y OF I`11E LOC{AL. AGENCY THAT 1',`;.`"sT'ECTS THE FACILITY TO A`Its'IFY THE ACCURACY Y ,,, THE'
<br /> I.NF RMAl(ION, THIS Alaf'1...1C AI'IO C:A'ti O'f EII:T'ROCII`SED IF TEIF BOIs'ACCOL)TN"1''aL'fi1Ii[,'l�IS`O"1't,'Ii.1—Li3 I N, rm l,of-'AL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY`USE ONLY 1N*F RMATTCs°ie'TIOX A;xCI`s'E°O
<br /> FOR-WARDING ONE 1 01tyl"A"AND ASSOCIATED FOR "B"(s)TO THE FOLLOWLNG ADDRESS, 'ITIS LOCAL A("xFNC Y si-tOt,LD
<br /> RE' AtN-'1`iii ORIGINALS A%S AND FORWARD TIIE YE LOW CORILS TO TII F'OLi.O INGi ADDRESS.THE PLNK COPY SIICAJILI�1111
<br /> RLTAiNED BY I IIF:J'ANK OW'xtiil:l2,
<br /> STATE OF CALIFORNIA
<br /> ST AIT IN A'1 ER k E:Si)L,'Ix'CLS Cr;C3r"wTROL BOARD
<br /> DATA FIt,{�CESSI\G CENTEE�
<br /> T',O)hG 527, ,
<br /> PARAMOUNT,CA 90723
<br /> 193 FOR012OR1
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