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INSTRU4ONS FOR COMPLETI, NG F(Oq "At'
<br />GENERAL INSTRUCTIONS:
<br />SECTJON 2711 OFTITLE 23, C:HAPTfiR 16, C:AL1FORNTA CODE EPEE REGULATIONS AND SECTIONS 25256, 25287, AND 25284 OF CHAFFER
<br />63, DIVISION 20 CALIi C)WNIA FILALTII AND SAFLTY CODE REQUIRE CiW ERS TO APPLY POR AN IST OPERATING PEi12MIT.
<br />1. One E ORlsl "A" sball be completed for all NEW PEWNUT CIIA'N EwS or any FACILITY/SITE INFORMATION CHANGES.
<br />'I. Thin form should be c � (1) I C'i� M "A" for a 1 acilityiSite, regardless of the atunrbi r of tanks located d at the site,
<br />2. SISi3LiRiL Cl�rlwY";")`s"L�
<br />ott,artcted by ci€h:ar the PE'R.�:II'I' r'tl-1111.ICANT orthe LOCAL AGENCY UNDd.,RG it3U.ND TACK INSP CI`O ,
<br />4, Please tyyx. or pi -nn clearly all requested inf'onnation,
<br />5. Use a hard point writing Inst rarn mai you are Wanking 3 copies.
<br />6. Tank wvn€sr insist submit a facility plot plana to the local agency as past of the application showing the, is ition of the LISTS with respect to
<br />buildings and hrarn,arkc (Sectiola 2711 (a)(8), C:C€2j.
<br />7. 'Wank owDer inn', submit documentation showing cx>mplii nce with sTdte £snsate al responsibilipt rn i zrc.ta c2r s to the Icacai agency as Part of the
<br />app
<br />lie,atlon f'< rff rolcuan L $J's (r ; t=,rrr 27,11 (a)(] 1), t CRC.
<br />'i P OF FORAria "!0 ARK ONLY i1Nli 1w1I
<br />Mark, an (X) in the box rle,,rit to the itcarr that frost describes the rexsorx tha form is being completed,
<br />L FAC.TLITYISITE 1.N1at)pMA'11t2Y,r Pr Aa DR.FSS(M ST BE COMPLETED)
<br />1. Record name and address (physical location) of the underground tank(s).
<br />s Cs"I'E: Address MUST have a valid physical Icx ation including city, state, and zip code,
<br />y:
<br />P.Ci: BOX l�iL MBE'RS AICE NOT ACC EPTABLE'.
<br />Include nearest cross street and name of the operator;
<br />2. Phone nwnbcr must have an area code. If the night number is the same, write "SAME" in proper location.
<br />3. Check the appropriate box for "T'Y'PE OF BUSINESS -OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc,),
<br />4. Check the appropriate ts>x for TYPE OF I3USENESS.
<br />5, If Ficility /Sue is ioca?cd within an Indian reservation or other Indian trust lands, check the box marked "YES'%
<br />6. Indicate the NhMIIIwR of TANKS at this SITE.
<br />7, Rec onl the E,RA, 11) # or write "NONE" in the space provided.
<br />1:1. T'iit)PERT'Y OWNER INFOICV1AIJON cg Ai:)I DESS (;AIL;`sT BE, COMPLETED)
<br />Cv`omplvic all it .rns in hi, sc, tiui5,. unless all items are the sarne as SECTION 1; If the tianle, wrhe'"S;AAa:, AS SITE"," acres, don section, Besove
<br />to check PROPERTY OWNERSHIP SHIP T YF I, ixax.
<br />ELTANK ANK O ,` ER I.'a¢ l^OR 'IA i [ON & AI)DIUFSS
<br />Con,pielc all urlins ir, lhls secti€ata, uarless all items are rhe starve as SI: CI"ION 1, _ S# MT' S SITU'aceoss, this ac t'tiaxii_ Be stiv;
<br />to ch A TA1` K r)'sG,'FRS 1 t PE—box,
<br />LV. iSC7ARD O i>QC ALIAZ ,ATIt.t_a U'S I'M t(AIh;4'i' 1iE e;t"3VPILi'ani. SLI AR
<br />DIVISION 20, CAI,iEaORNIa1 illiht."S'a i�� Srtlili`IR t C>%I:-?
<br />L.,.tc.r your lioa . of ,_.r.. ,,. ,.t,,;ir (BOQ UST s+crngc fee acct an"t trunci) t ,S? .ch n'., in:'i t , t,,;,., } t . '11:m -,ii
<br />Pc. ,,moll with 11 B01" s,it: ,,,,, ure th,n ?,ou vxdl ren;-dvc €a ctuarttlily s > , e Ia,.. r, .,a.>a ill ra r' a:�ag �,._ .ati S F� .i3 #;s� t t ' ;,a> f. , due on a.hw
<br />,ria�n';l .r c,i 1
<br />„<.l e .t, a,�u�az ., y Sas US] s, T I t. 11C a Alt cute f . ,o€sr om,1-0} [ icor. , at, .> r t E . , >:ci;c t t, s 3 _ ' r n you d a not .
<br />ha,ec.an v"'J" tlaa. BO;, ,,. i; you has'c an y uaae.st„on =
<br />_ te> tlza, taOIi aa dl.0 ic. 3� h ,ra a i;ta;;= Boardof I:,iicr:al;latrurr, l°mel I'ames Division, P.it. iaox 112"'l19, SU.rra;,a;, .., {...r::J1"' 9 ('001,
<br />V. 111,>hiLC)S.l.t Yl :.`S", FINANCIAL i\FSPONSIBIJTY {,,, STBl-- CO%IPI 1_:l is FOR 11E IROL1,.E. N1 �,S.'l, i NL) , Il H `, .(A.iso
<br />CiF'ITTl.l, 2 a, (,'I1 A.'1Ti,K 16, CAI_;I'ORNIA CODE, 'O €L..tltiti..ATIt?NS
<br />Tdeii€ ify tho r~t .eoal.;,a x, cd bV thu owric.r ar,ct,or otscra or, an niueting th;1°cdcral and Staab a,r _,uia.I .0 i a,.. �:e t sa..�.r.�at:z, US -1 )y
<br />any 1 ,,,dor,al or S..<t atcr. ,.y ss es°c,l a; Iron -pst,olusm LSTs arc exempt from this
<br />VL 1,EGAL N 01 flICATION >Y°,I,7 PILLiNil ADDRESS
<br />'Cuer:k ONT BOX foo the ..dli.e s that will by rlsz: for BOTH LF'%GAL. AND ll,11.1,1NCi NO f ll 1C A]'!�, siS,
<br />TANK t`)'4� Nn":iL OR #AL t welt z>L13, a Zl:.f'llf.SENTAIIV;, MI S SICs14 ALT) i2ATE a 3 €„ FORM 'i #,,s C. „?€i ). [,SEI. ... (A .c,N S 21
<br />(a)t13 f OFTITLE' LE' 23 C"ITAII11,"R 16, i'..`I.11FORNMA CODE 01 REGULATIONS]
<br />INSTRUCTION UCTION 1,0,q 1 S1T�' I,CICAL AGI'NC II'sS
<br />1lc County all jurisdiction numbers are prc:ictc;raxrirred and can be obtained @ty ca°3aar{ the S'.ate Board t t, aft,, 227 4303.
<br />:.t l..y...e nu, -O --ex allay x,>
<br />assif;r'cd by the lot al tag ..,a , , irov ever, this number must be numerical arid cannot c,omain any alphabetical characters. of t` e local age1 cg
<br />the Stat. Ifoarc, to assigas he facility taunrber, pjcase leave it blank,
<br />IT IS TH EJ,1LSPONSISIILIfY OF THE LOCAL AGENCY THAT INSPECTS THE. FAC':111TY TO Vi RIFY THE ACCURACY OF '11€h
<br />LNFCJRMA°{ `()*s, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCCIi:lsl'1T NU;1 ,,IBER is NOT FILLET? IN, THE LOCAL
<br />AGENCY IS 1ZESS'ONSii3l.l`< FOR THE COMPLETION OF TIIE "LOCAL A(jl NCY USE' ONLY" INFORMATION 33C X AND FOR
<br />I°(}Styl'r11Z17ING ONE FORM "A” AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING rAi)DRE' iS. THE LOCALAGENCY fillCiULD
<br />RETAINTHE i ]RIGINAI S AND IrCikCWARD THE YEt.i.C34V COPIES'hQ-THE FOLLOWING ADDRESS. THE PINK COPY SHOULD BE",
<br />IZI:` AI F"D BY`I111 e'ANK OWNER,
<br />STATE OF CALIFORNIA
<br />STATE E WATER RESOURCES CONTROL BOARD
<br />00 S.W. },,,E,S'. .
<br />ITA PROCESSSNG CENTER
<br />I1.0BOX 527
<br />i'r�iZAl�' OU i', CA 90723
<br />39:i FOR012OR1
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