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INS'pI(:(.11,() S ) =-,ONRI f I ..,r = 11,Gtr.., I
<br /> � ;1 �. rz 1kfi' & ti hSr� ' ktkal $�` �l� . , ly111
<br /> INFng `
<br /> w ly a do RNT of
<br /> _. Sgp�� ���a_�l�a2� .a� p�at�7s�a for LLa. <.€s��k,r�33+ yy ygy,�e�tqqlcYY��v�pp o. �__.a��,;..�be-p,q�fpgt�pp_€rps�pSi 1v€q3q��r_.�ii„14 yti_.3 ,t,A,.
<br /> 'I'lus onu, .raad,>�lei tl Y.i'.,:r.r{.c. b"4 SSM. We ��l.t�.MI .�PPl�.:ICA-rBf'o the >•..��ni�CAE AGENCY�..,P U '.��`f,�£';£4�f&O��Y�ND
<br /> TANK INSPE,(7i01d,
<br /> 4 =rid r .. r .`,ti .. ...a=.:S EZ£=C,S7..1,ic,:JY3,
<br /> x.,
<br /> a, an J) ill _ box mv 10 the r._ar &A he. d"CAns we r_xMrr, w. We >. t .tieg com,Ytr;c,wt. ,
<br /> f.,srl'Ti- IN IG3TCS*. ,t,. , & ,x1;f)11TCCS ( (,.7 p HE (rtsIa1PfjiI'ISI))
<br /> 1 Record 3.£azl c ,and aMmv („?,iy.) location) of the 1n&, }=ownd zitfz�'i R,l,
<br /> siC?"1'I3: ARms Irri.sl' h v a vAd,AdMMIM Ioc<alln rr3a°Ecadkg city, ;,tate, and zip cele:
<br /> F,C3, IIC)X NUMBERS ARE Nur AC ?,vr AIII)a
<br /> 1riclude n"ma a cross street and tsame of the salierwo
<br /> hltc=ne nrrrtabc:rar'rcae,t Cave an wrea aoilu. If mea iai °at r2xrnafi,er is the same, write "SAME" in ptY.ct>e:r tota4[<ari,
<br /> Check the xppr inia€e box for`[YP OF BUSI`I,:SS 0'aYN '3RS11111 (ex, C`)IaI'C:)BATION, 1ND1ViT)UAI„ os.)
<br /> A Muck k Me aisfa =gi atsr box f.»r"T"Y FI OF BUSIN S.S.
<br /> 5, If Facility/she is located wiflini art Indian reservatian or other Indian !rum Inds. cheeA Be box nuutca9 113",
<br /> €i. Indicate the NI,MT FR of`,QAN. IS at this shS'T1„
<br /> rn Record Be T_,1",rA.. 1:(3 # or write "NONE" in the space pi-oviJccl,
<br /> I. PROPEKEY OWNER I TXIIT °A",I°TC) I , ADDRE-S's (i Lis BE (XNWP11nTY10
<br /> C"csrraplet.e all Ams its Mis s+uc:.ahm unie.ss aR itms raze Me s<me at,, SECTION 1; it the same, write 'SAMEAS WITT a u ss
<br /> phis smthm Ile sure no check tick 'ROP11,1e'T'Y OVVNE161HP 'l:PI? €ox,
<br /> III. TANK C.Bi NER hNIZOWMA1101d sC €YT,)I)RF`,-5,S (INIT.ST BE C"C)MPEv'nil))
<br /> C;orraphle Eat[ itms in At ,,.._. .'.r, uAws all rtes,.,, uc ttae same as SII O' l'ION' 1It the ha32zrC. arhe "SATCK Al S111, <a..m,
<br /> r.s scctirn, Be ,ure ,i, c,rcck TANK G:f'sS IR-SITIP"I'YPE' box.
<br /> IV. 10 ARD OF 1 KTU AI<Ia'A310P UST,1�7I'()IC G E i"fiE, A(.'CC'YL bO'NIJMRE C ( L)SF TTI T'T ; T. )
<br /> I.iatear your Bowl of T ,rhaizaW F 0149 1151' worago fee a€.d.ouna number vvhkh is mcitzirreal fax^btu your permit ,afiph, aiion
<br /> mus be procusccl. 114mindOn MM i. €e HOE matt ensure that ycu viii receive <a quarreriy morage fea retmm in mpm ing tlsc
<br /> $f M06 (6 mils) per a,aHou =°c:e dm on the nawnaser of IpHoss pined in rwr IJSIT 'Ile BOIL, will code persons exempi :Merica
<br /> puy;tg Me sraarMc fee so r;.oms aarll not be sent. U yon do nor have an aceotr t number 00 On: fMF or if veto ham any
<br /> questions regarding tine fee or v:xemptiorss, pl me will the BOB at 91£4323„9555 or writs; 0 the i3OE m tM k 11€)wing <actdms:
<br /> Bond of Equaikahm, T.,rr,sc;amemai 'Itees Unit, P.O. Box c1T2^71), Sacnamento, C"5, 942=01.
<br /> T 1"s'T'i1(aT.T UM 1Wr I`INANCI,AT, T1I3S'C) SIIIIE;IIV ( US-r RE C OMPI,irma))
<br /> 'xdenl.i.iy the r,et:.od(s) uold by tore c.€wne, and/or operator in meek, n.lw Kninrai and State firsaanchl responsibility
<br /> requi mems. Utas o,vi a el by any Fccleral gar.fiwo agency are •,olerfd fix-n this rr✓al>o irenle tt.
<br /> VI, 1 E CITAT. (Y11a C'WI1O ANI) TTIT:T NG«DDR 5S
<br /> Check ONFE BOX for Ow address that = Ise esed for BOT'il 1,I;CT I:.AND 11111JIG G NCI`[TIq,(: 170NS.
<br /> tAlaC'i::CC”.i ` I I.Is r SIGN SAND i /VI 1;11 E:; FORM AS INDI `.11:1).
<br /> I 5LTC 100 'aO1C 'I 1 , 1,0('Ysda aAGEN(JUS
<br /> The county-,and Ta ns'diclion nkinnixers, arc, predetermined and Can he ottained by suiting the State Board (916)'739-2421. `I,lm
<br /> r;,cili, nt,? 1ecr nay to; awQxd by the local agcne . how-cneo, This s.e,Wmr mum be numerical and cannot contain tarn;,
<br /> WT,xsaV�(:arg°tgissr?.g If M [ocar x,rv,n probe, t ay Awe. !bud i a�4,rkts ,t,c.m�r<z,:,lr3tar nes}nfae:n place lqc�.rue it Iflank, �gg
<br /> I�T..IS p.i% Iu &t.��PC)NS,1BIIri`1 01 AI�. T,€,3&x..4''JL,��°att,Pa3.:t'�(T F h.A.AT I1�x'?+.PE(7T '1111 FACII..IYY �.IO VERIFY71113
<br /> ICC;:U CN C)F'T` HE I'SI=C)TI" r'A110 . `11I1S .aAPPLIG:rA'TEC))T (INNN I"T'IIE PROC.InSSF ) 1F°11171 l30U, C; ;OONI`
<br /> NUMBERIS Norr Ffux,,, IN, '17113 ITKA1.,ABINCTY IS REWONSIB[14,F11 C'0M I1q1ON C)F"TIE
<br /> "E,OCAI.AGENCY(;FSIs" ONI,Y' INIS)I1MA`T'ION 1K)X.AND FOR FC:)TC V.ARDING ONE FOR "rA" AND
<br /> 5 1'Cx`T'IE OF C AJ II ;) . L
<br /> f a'rY'G°I'< W :T S)CJ (C)9IC)T.1
<br /> /Gaa"ss sa u-"1 a
<br /> DNI`r'r I"ROCp QST G.'s CI 11410
<br /> PAI BOX 527
<br /> IRARAM :a `I, COY 90723
<br />
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