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<br />TANK INS)",if "OR,
<br />plems: sq, 's pnre cieadv, nl� 1eslwlNxtcd hlfokenol��ow',
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<br />L FArin."p.,ni, INIsoRm—AlION & ADDMNS (W51' BE', ('x)M#'NT1i0))
<br />cat mme MW no Mas U1
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<br />11,0. BOX NUMBIAW% ARE N`1'ACII `sJ', RLP',
<br />Include inamst mrs,,,uri.o and name oftiin
<br />1 Plame nwWvr mum hwe mn .oma code. If Kc noly nwWr is 03 onw. mic "N %W" in poper
<br />3. Chmk Hoe appi-opriata, box, forl-YPE OF BUMMAS OW\FRTIT (on O)RIT)RAIMN. 1NI)ATY: %I, cW
<br />4, (Arcck The fto+1'YP1-,', OF 131,JSIN—Iks�s,
<br />5, If Facility/Sac is ImMed witIvin an ImHan rinervatkan or odier Rdmu yam hodn check Aw box lan0d ") W
<br />6. Indicale the NfJMRFR ()fTz`,,-NKS <u Oda STYE,
<br />Rnswel Ole EPA. 1D 0 or whe "NONIT' in Me s1mov: panAW
<br />11, I'ROPI,,,RTY' OWNER, INFOMMAIAON & AT)DIfili�",, tftu"si. ,;I,
<br />Co"kin: A Ams & to smon, None all hem; No On sanc, aS,a Kw:,' 1, wif who sanw, We WANM AS 14110
<br />i Ws seakm 10c mn-e to chock PROWE'BA Y OWNE)ZSHf1, I
<br />111, TANK OWNER INFIORMAIION St ADI)FUSS (Musr nu
<br />WillQue aH ka" in no sian", eivesa a Ams am Me ,own as A XTKW V if Ow swro. wn: c BANNS AS sitly wRo,
<br />Ais maelion, Bc m,o'c, a,) crla-,ck TANK OWNTi-RIVIII' IPI, nox,
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<br />Enwr yemr Word of fAmUmAn OKMQ USF mmapp Re ammm .,w ..a. what a, mqwmd IwWm yaws pnow apkwi,n
<br />cail bc, potcessodi, Registrittkan %Qh the WE W emure Am Im wW rum, a TNwl-,cvlcv l,woraga, flic return ill 11a,
<br />SUN 0 Ws) fen p&= Q on on Me number of pikes pKA in yar LAIL The HIM wiH ends, permis cnempe Ani
<br />paying the stornge fee so mmms AH not be seni, If you Q no hove an amount num1wr sit the JAW or I an kmo wnis
<br />questions regarding fire fee or exemptions, phease call the 11ME w 016-M19,155 or w&e in As M11 W Ow Rkowing Kdrmv_
<br />Bowel of EywIntioa, E*,livironnsental Face Unn1"Al Boe 942879, Sacramento, CA 94. 79,,K)()Q,
<br />2 11T1ZtHEUM LEI' FINANCIA1, RISPONSIBI111Y (M091AW, COmml-n1il))
<br />Identify the method s) lawd by she owner anqnr oyami sr in mnow" aw I anva "d sac ninam W Im,me army
<br />rNunimmma. LATV numd by any Federal ov Sume arm ny am cecmW Amn mis aNwmwn't-
<br />Ian. IEGAI, N(YIIFJCWf1ON AND
<br />CAW ONIT 1KJX Asr the address thrit lviil ne used Or IKXIT ILEX`.. I, AND 13111114(1
<br />SIGN AND DA -M.17111-', 1k)RM AS INI�ACWIIfi-x,
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<br />lie amnq and junrisdahn nandwrs are predeternlinwod and.,,,5ino, ro nd lied bw'a1il a, Saar e Board (916)739-)42E The
<br />jllaylo; assigned by ths, local agencN: p"Qu nw- be M.WN no C"MA mrawn "Y
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<br />phabcficsiL if lhe h"'Cal agency puRn he Swe Board to nvWi Ac 044 n"Ta. ""n We A b5i
<br />FF IS 1111: RT,,S1"1,)NNIBI1Xj1Y OF171H 11OCIA1, 1,111,61121-11Ce", "Ill It "s,'"'i' T11111F fjAWIT 110 `IWITRUT 11M,
<br />ACCURAIN W WlE INFORM N)ION, 'FIRS AITEKZIIO14 COINfACNAH; 1TWASTA) WTHE
<br />NUMBER IN NCYF 111,Hil) I -A 171F, 1,A)CA-1, A61,211KN, Is C'Os,,1,111�110N 0i,''111E
<br />"I,X)C,'A1, ACT'NCY OSE ONIN' INFORMA"FION 11OXAND I[AIR f0R17'k? RIXING ONIT K)RAI "A" AND
<br />A!'WICINFED FO-WM, 13'(S) TO '11IF', 1`01AX)WINGi
<br />:31WIT, OF CA11FORNYA,
<br />5FAIT WAITIR RE-5X,3U1i4'FS (WIRCA, III RI
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<br />FWIA PROCISING (1uS`A'F,1Z
<br />L,0, BOX 527
<br />PARAMOIJKI�, CA !Y07123
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