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INSTRUCTIONS FOR COMPLETING FORM W GENERAL. INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERMITS, PERMIT CIIANGIS or any FACB.rIY/SfIY. INFORMATION CHANGES. 2 SUBMIT ONLY ONE (1) FORMA" for a Facility/Site, regardless of the number of tanks located al Us site. 3. 'Phis form should be completed by either the PERMITAPPLICANT or the LOCAL.AGENCY UNDIgt(iROUND TANK %NSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point wTiting instrument, you are making 3 copies. TOP QF FORM: "MARK ONLY ONE I'T'EM" Mark an (X) in the box next to the item that best describes the reason the farm is being completed. F. FACILITY/SITE INFORMATION & ADDRESS (MUST�BE COMPIEETED) 1. Record name and address (physical location) of the underground lank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACfINTABL Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'UON, INDIVIDUAL, ac.) 4. Check the appropriate box for TYPE OF BUSINESS. 5, If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. I. PROPERTY OWNER.INFORMATION& ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; if the same. write `SAME AS SIZE' across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. IB. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPIEIED) Complete all items in this section, unless all items are the same as SECTION 1; if the same. write "SAME AS SIFT?" acnss this section. Be sure to check TANK OWNERSHIP TYPE box. N. BOARD OF EQUALIZATION USI'SPORAGE FEE ACCOUNT NUMBER(MUST BE COMPIE177)) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receivea quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the 130E or if you have any questions regarding the fee or exemptions, please call the BOF at 916-323-9555 or write to the'BOE at the following address: Board of Equalization, Environmental Tees Unit, P.Q. Box 9424379, Sacramento, CA 94279-0001. V. PETROLEUM USI'FINANCIAL RISPONSIBILM (MUST BE COMPLETED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BCrITl LEGAL AND BILLING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL,AGENCIFS The county and jurisdiction numbers arc predetermined and can be obtained by calling the State Board (916)739-2431. The facility number may be assigned by the local agency, however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. rl'IS THE RESPONSIBILITY OF TTIH LOCAL.AGENCY 'THAT INSPECIS TME FACILITY TO VERIFY 171E ACCURACY OF THE INFORMATION. 'ITIS APPLICATION CANNOT BE PROCESSED IF 171E BOE AcCOUNr NUMBER IS NOT FILLED IN. TIEi LOCAL.AGENCY IS RESPONSIBLE FOR'LITE COMPLETION OF TTIi 'IA(N,AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSCX/A7ED FORM "B"(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA SPATE WATER RESOURCES CONTROL BOARD C/O &WE.I?PS. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, (A 90723