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INSTRUCTIONS FOR COMPLETINGM
<br /> "All
<br /> CiI:N;i;R-kL INSTRUCTIONS:
<br /> SE,CT IC)N 2711 C)l``TITLE 23,CITAP-1'1 2 16,CALIFORNIA ALIFORNIA CODE OF REGULA-IIONS ANAs SECTIO S 25286,25287,AND 25289 OF CHAPTER.
<br /> 63,DIVISION 2(},CALIFORNIA HEALTH AND Is.1IaETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING R MIT.,
<br /> I. One FORM"A"shall be completed for all N Ind PERMIT CflANCTI S or any FACILMISITF INFORMATION CHANGES.
<br /> 2. St}BMITONI LY°ONE(1)FORM"A"fora Facility=(Sita,regardless of the number of tanks located at the site,
<br /> 3. This form should he completed by either the PERMIT APPLICANT or the LOCAL AGENCY t1NDEIZC"siLOU.ND TANK INSI-, ORf
<br /> 41 Please tope or print clearly all requested information,
<br /> 5. Use a hard point%orating instrument,you are making 3 copies.
<br /> 6. Tank owner m6st`submit a facility plat plan to thin local agency as part of the application showing the location of the USS s with=respect to
<br /> buildings and landrnarks[Section 2711(a)(8),CC:RI.
<br /> 7. Tank owner must submit documentation showing;conrplian 'With state financial responsibility requirements to,the local Agency as r4ft cif tits
<br /> application for petroleum USTs[Section 2711(a)(I 1),CCRJ,
<br /> `TC�PfITC)1t1vJ:9, IRC)INC.. {)a}3I'C"liM"
<br /> Mark an(X)in the:box next to the it.ent that best describes the reason the f°onn is being completed.
<br /> L FACILITY/SITE INFORMATION&ADDRESS(NiUSl'T3E COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address NIUST have a valid physical lavation including city,..state,and Zits code,
<br /> ROC BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Includa nearest cross street and name of tire operator.
<br /> 2. Phone number must have an area code. If the eight number is the same,writer"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSENESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE{7F TILSINE'SS. :S
<br /> 5. If Facility/Site is located within an Indian rt sery atiun or other Indian'trust lands,check the box snacked "Y l:S".
<br /> 6. Indicate the N UAhEER of°I'ANKS at this.SITE.
<br /> 7. Record the E,' '.A.TI)#car sstlte xCJNF=.in tare apace provided.
<br /> TI. 1'ICC:3PE"RTY C)V,".''ER IN1 t7I2M=t"TION&ADDRESS(MIUSTBE COMPLETED)
<br /> Complete all isms in this section,unless all items are the same as SEC:"l'ON 1,It the same,write"SAME As SITE""aerois this section. Ile scare
<br /> to check T'ICC)PERTY OWNERSHIP I'Yl'i::
<br /> III.TANKOWNER INFORMATION&ADDI FS8(A'SU I"BI COMI)IJ--rED) 11
<br /> Complete,all iterns in this section,unless all items are,the same as SEC.IION I;If tic saine,write"SAME ASM T', icrors this ss etion. Be sure
<br /> to check"t ANK OWNLRS TYPE box.
<br /> I4'.IlC)d11tI.)C31 l()L Al ClA`l'It)N Tis'I I"iJIt:1 r,.I F:: AC'Ct)T;N I'Nt tllllil2{v!it)s"C'I3Ii Cs'{) ll'I.E"I'I,,D 4EE AC t"i{"i.t,*,(.IIAI'"I'I',}C
<br /> DIVISION 20,CALIFORNIA RN IA 11F AL l-II AND SAFE I'Y COI}h,)
<br /> Er;t r ytsar 13,7<are,'of Fqc.alaz.tac,at(t3Ur�j L,,1'strsragc fee aeoor<rrt nuisaher�xhicla i.rt•quis'exJ beCvx%ycrtrx perr�,tt Baa,.lic,ati..;a__:rr>r l,r:r<'e,�c`th
<br /> R gi,t.tation with flaw B(A,'a M cn t.:c that you W1,11 receive a quarterly sturagO lee.rctcIM i1i reps icing the SilAM6(6mil ,,,,i„-ls>..fee due on t3,-
<br /> tl+es'vF ga fl ons I>aat,,,i iny r US=s._Fh.,30will c c;e p rsonr excna}Srf cs n raying the st<yei,,,f e so rcllun,s v,.1.,e If you do not
<br /> laat°s,all.account astarr bcr b:ith mu BOH or rf�>�: have away questions'regarding the lQc or cNemplions,pleas call?„c`BO ,<k, ��;(,?.? �3 fir)
<br /> to uh(u BOE,at o-'ee, aaddl ss Board of Lilualizatio t,Fuel`Faxes Division,11,03 Bo-i g1211i7;1,4<acern,e:eat€s,('A
<br /> V4 Pl:;iliC):.l:u ;UST FINANCIAL 1Ct;`PONSIBTLf`I Y(MUST f3I.(;E?Ml'l.l:TED I R UST: 0'!,Y,£i) Si-(:J s`C».>2711
<br /> Ol"'I'l'Il_H,23,CLi.YC'tT R l6j,C ALIFOR NIA CODE 0 KLf 1C.IhATIONS.)
<br /> Tdei Lily elle mc,Ctc.xi(s)u,csl by the ov ncr a<:d/Orope'-rotor,in rilecting the l r&,ral and Siatofiinacacial scgwns�il,rttty UsTs.rs ....i by r
<br /> ally Fcdcial or State agency as well as nona R it-ol um USTs arc;exempt from this.€equirci rcpt.
<br /> VI,LI3GALNO11FICA"TIO AND BILLING ALJDRE'Ss
<br /> Cheek ONE BON'€ur the sddless trait v,°ill be,.yea for I3t3`iH LP:(IA'h AND I3Il.I<TxC N{1"1(E`':IG`A I It.3Vti,
<br /> TANK OWNER C):?AI;"1"liORIZE'D REPRESENTATIVE MUST,SIGN AND D; TE'.'I'll1�,t=ORNI AS INDICA{'i D. ,...,.a.°�E(3 0"`s I I
<br /> (a'){I3)C}i%-1:c 4`1,€i?3 Cl1 AI'l'I'ilZ 1 a,,C:'r1.IhC)!�'NiiC Cf31)F C}I^' 'k:Ct,;t rl'I"CC3,N5.i _ -
<br /> TNTS"1`I UC'I'IONFORTHE .00:ALAGENCIES
<br /> The county ar L arsflictae n numbers are pc d;terrta=.ned and can be obtained by calling the States Board 1,I16)227-4303.
<br /> assigned byfhe local agmen;bows vcr,t,lris number roust,be numerical arad cannot contain any alphabetical characte". If t1 oi(c<al,agency pre crc
<br /> the Stats;Board to assign the facility nurtrbcr,please leave it blank,
<br /> IT IS TUE"RI.;i?'{jNS11311,rl'Y OF Tlt1s LOCAL AGENCY THATINSPECTS 1`S TATs I ACI,.ITY"10 `ER'FY THE AC:0,3RAC°Y Of,' THE
<br /> INFORMATION, "C'1'1IS A11111,IC A°l ION CANN4:T BE PROCESSED IF THE BOE ACCOUNT NUNIlll it IS NOT111,11"D INTHE LOCAL ;
<br /> ACiliNCY FOR Tztl; COI%Mt'LEIION OF THE LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONI l-C`sRM"A AND r`rl,S0 lAED PCOM°l3'(s) TO THE FOLLOWING ADDRESS, THE LOCAI,AC E.NCsx`SHOULD
<br /> RI tAll,`JlIl QRt 1 3INALS AND FORWARD:&HL YELLOW COPIES TO TlItFOLLOWINGADDRES5. THE PINK COPY SHOULD BE
<br /> RE"TAINE"D.B lHE'TAINKCU'iGNER ry
<br /> I WTI:OF CALIFORNIA
<br /> STATE WA IT'R RESOURCES CONTROL BOARD
<br /> DATA PROCESSING CE—NTER
<br /> t -• i' l t P.C.BOX 527
<br /> l` I_ j$s
<br /> ,� t,a I'd1ltAMC?t;mT">CA 90723
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