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<br />INET I kION r S
<br />LE TING "A"
<br />GENERAL INSTRUCTIONS:
<br />SI C,r,'ON 2711 01--1 ILIE, 2:3, Cf IAPTER 16, CALIFORNIA. CODE; OF REGULATIONS AND SECTIONS 25286, 25"287, AND 2,5289 OF CHAPTER
<br />6,7, DIVISION 20, CALIIaO NIA Ill>AL.'FH AND SAPETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPE'RATI'NG I'isIRM17F.
<br />I. One FC)I£4f "A" shall be completed for all'N EW PERMIT CHANGES or any FACILITYISITF INFORMATION CF£ANGE &
<br />2. SUBMITONLY ONE, (1) FORM "A" for a Facility/Site, rep ardle:ss of the number of tanks located at the site,
<br />3, This formshould be completed by either the PERM! r APPLICANTor the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. Please type or print clearly all requested information,
<br />5. Use.a hard pointwritinginstrument, you are making 3 copies:
<br />6. Tank owner must submit a facility plot plait to the local agency ai part of the application showing the locationofthe U Ts vaith aspect to t.
<br />buildings and lamirnarks [Section 2711 (ca)(8), CC 1kj.
<br />7. Tank owner must suttanit documentation showing eomplianre,with ,state financial responsibility requirements to the lopal agency, as,part of the
<br />application for petrolcuzn USTT [Section 2711 (a)(l t), CCR], q
<br />TOP "MARK. Ni', ONE ITI:;~,+11"
<br />Mark an (X) in the box next to the item that best describes the reason the forret is being completed,
<br />t. FACILITYISTIE INFORMATION TION & AT)i RIR S (.'NIU "f EE'COMPLETE.L)
<br />1. Record name and address (physical location) of the undcrground tank(s),
<br />:NOTE/ Address Mu 'i.have a valid physical location including city,; state, and rap code.
<br />P,O.,IfC X Nt,MBERS ART. NOT ACCE'vrAllLF.
<br />Include nearest cross street and marae,of the; operator,
<br />2. Pbone number must have art area code. If the night number is the same, write" ATNIF" in proper location. .
<br />3. Check the appropriate K)x for TYPE OF I USENTsSS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc;.).
<br />4aC°heckthe appropriate bcxfor `i:YPE,OF LSI�1:5... a
<br />5. Lf racility/Site, is locawd within an Indian reservation or tfther Indian trust lands, check they box marked °YE,S"
<br />6_ Indicate the ,tii:ytlBER of TANKS at this SITE:
<br />7. Rocoaci ili'c 13,1`,A. Ili �4 or write " Ni NE" in the space provided.
<br />l:.. PROPS"RTY C3Vt NIx ,R I'Na OR-Mr1' ION & AIND E'S.S (MIUST BE COMP E-11"13)
<br />Complete all items in this section, unless all items are the saner as SEC"III N 1; Ifthe wane, w6te `S AsAE AS KIT," across this section, Tic sure
<br />to check PROPERTY CIWNE161111' TYPE box.
<br />If!, 'T ANK OWNER ItiitORNIATION & ADDRESS (i1L 4"I` T3k=, CCiL3i'i.rr.T D)
<br />complew all iterus in this section, unless all items are the saran ai SEMION 1; If the sataar, write "SAME. AS SITI-- acums this ss:ctzen, Be,;sgnr
<br />to check's"ANK OWIN'i:R;i'I'YP box.
<br />IV, BOARD OF I:(itlAI l.ZA`I"l \ UST SToRAGI. FEE !eC'CC.9i.'NT Ni MBER (°JUST BE C°ONIPt..E'l l-, i1, SEE AR11 aC.l ' 5, ("ll ilaF ER 6,`75,
<br />DIVISION 20, CALIFC3£LMA1,EALTH ANT) SAT T:TY CODE)
<br />Iarf>r your Boar", of ({3(dI:) UST aro^ae fee aer;ount ntn?ser ,�vdich is n 1tr€rc 1 Ix rur> year ,x:,rraEff al t..ic:<tr€.>,a a,>:ai;;c T}rue4>cd.
<br />R,-,ga;.umlion ; th uhc BOt,, u,,; ensurc that you will receive a quarterly storage fee r. turfr ifl, rcpc)ating the a' a i,.dlofi Ste dais 4>rr the
<br />nuinbc,rof'galkriplae d ar, g'<rur ,a l: , "llae l3OI will code,p Ksons exe npcfrom payin" 01c, storage fee sea r t f_r.,, wail i of be s.;rai, li you do trot
<br />have, aft ac;coum tnwnbar N�ith flat; B01,13 or if you have arty questions regarding the Cru car ea t.asslaficxzs, I>3easc; c.atl fle- BOE at 9.116 32. 669 or wratai
<br />to tlw BOE, At the ;olkm ing address Board of Equalization, Fuel Taxes Division, lr.C). Box 942679, Sa,.raubcaatu, C:xM 94 , <. 4 < .rt1.
<br />V. PEITSOLEL;M1 US t' MNAINC IAL RF'SI1OJNS ItlIwIT'Y(M UST BL C O.MI'LliTEi) h<7Ta 1'1 "S IC(1:,[,1tM1 t IS I s ONI Y, sl"T SFC1 J0NS'2'il l 6)(S)
<br />C)I'`l"1'I`i,!.23,t:.I1.11'1'JilZ1Ct,C;rel,lla(JR41!tC~:C)I�1;C3P%1LiaCa(J1.,11`l'1O�(a.) � t .,
<br />Identify the nictlacxl(e) uwd by the owner anktlor opewo r, inirecting the Federal and Slaw. filkarwial responsibility Tequircaakc.fat , 1 �ST's by
<br />any Fedw al or St arc, a c;racy as well as non -(ctroleum USTs are excr pt front this tcxluizc rauarat.
<br />VI. S..T:C3AL N041FIC ATION r1NI?BILLING ADDRESS
<br />Check- ONE BOX for the, adchcss that will be used for BOTH La1CIAL, AND i3SLT,i aC'3 NC3I`.3I I{:°,�'1It;7 �:S.
<br />TANK + WNER Ok AUTHORIZED ED Rl l'12t.51's"£"I'ATIVE II; "l' SIGN AND DATE TE11-11 Er£.?IM AS INDICATED, 151,5' ,,"j(l ONS 27t 1
<br />(a)(13) i3F TITLE 23 CHAPTER 16, CAi_IFOR N t1 CC3UI: OF REGULATI£1N"S.1
<br />ENS"IRUMIONFOR Ilii::
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