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.a..a�.aw,-�s^..,R;I<,•,._"�T'Xln+is:wr .PRT.-1.wv.— - 'Rlafna-'. ... 'r INSPRUCIIONS POR COMPI, 'A' GENERAL INSTRUCTIONS: I. One FORM "A" shall be completed for all NEW PERMITS,PERMIT CIlANGFS or any FACILr1YJSrl7? INFORMATION CHANGES. 2 SUBMIT ONLY ONE(1)FORMA'for a Facility/Site,regardless of the number of tanks located at the site_ .1 'this form should be completed by either the PFRMCC APPLICANT or the Lf)CAL AGENCY UND£i.RGROI TNI 'L'hNK- iNSPECFOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. 'IOP OF FORM: 'MARK ONLY ONE rTL+M' 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FACILr1Y(SrrE INFORMAITON&ADDRESS(Must'BE(HMPIYPED) 1. Record name and address (physical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city, scare, and mp code P.O.13OX NUMBER ARE NOT ACC EVPABLE. 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 !,::,von. 3. Check the appropriate box for TYPF OF BUSINESS OWNERSHIP (cx. CORPORAI ION, INDIt'Ii)I At,, cic.; 4. Check the appropriate box for'1'YPE OF BUSINESS. 5. If Facility/Site is located on land within an indian reseontion or other indian ;lust lands, check the box marked "yGS'. 6. Indicate the NUMBER of TANKS at this SETT.. 7. Record the E.P.A. ID #or write "NONE,"in the space provided. If. PROPERTY OWNER iNFORMA770N&ADDRfS.S(MOST BE COMPLEIVD) 1. Complete all items in this section, unless all items are the same as SECTION 1.; if the same,write 'SAME AS SF113'across this section. Be sure to check PROPERTY OWNFRSIIIP IYPE box. %id.'I'ANK OWNER INIrORMA'ITON&ADDRTI4S(MUST'7 ? COMPLETED? 1. Complete all items in thin section, unless all items ars the same as Sf CTTON 1; If the same,write "SAME AS SfPE' across this section. Be sure to check"LANK OWNERSHIPTY1114 box. IV 13OARD OP IBQUAI.IZATION USC l 1l ORAGE I71I AC(X)UNI'NUMBER(M(JSi`Eli COMi'LEII3D) _ Enter your Board of Equalization (BOP) UST storage fee account number which is required before,your permit application can be processed. Registration with the BOF,will ensure that you will receive a quarterly storage fee`relurn in reporting the (6 mills)per gallon fee due on the number of gallons placed in your 11S"Ts. the BOF:will code persons exempt from paying the storage fee so returns will not be sent. If you do not,have an account numhcr with the BOL or if you have an,i questions ' regrading the fee or exemptions, please call the WE at 916-739-2582 o,conic h,t the BOF,at the following address lioard of Equalization, Environmental F'c�s Unit, P.O. Box 942979. Sacramento. CA 94279-0001. V_ LEGAL N(711FICKPION ANI)BILLING ADDRESS 1. Check ONE BOX for the address that will be used for B0111 I TXX:AL AND BILLING NC711 ICA'TIONS. APPLiCIr p MUST SIGN AND DATE 11E1 FORM AS INDICATED. ` INSIRUC 1ON FOR THE LOCAL.AGENCIF-S The county and jurisdiction nu-mbers are predetermined and can be obtained by calling the State Board (916)739-2,121. The facility number may be assigned by the kwdl agency; however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board N assign the facility number, please leave it blank. rr IS mE RISPON5113un Y OF THE LOCAL AGE.N(Y TIIAT INSRECI:S'Ct1E FACIIXIT T)VERIFY THE ACCURACY OF'PHE INFORMATION. 'IRIS APPLICADON('ItNNorr BE PRO(T SSI:;D/1711111 BOB ACCOUNT NUMBER IS NOT FIIA.ED IN. 11E?I.()CAI.AGENCY IS RFSI'ONSIBIS?POR IIII3 COMP11'.110N OF IIIL"1,O(AL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIA'RiD FORM 'B'(s)TO`I11E FOLLOWING ADDRESS. SIW`PF 017 CALIFORNIA SpKPF WATER RESOURCES C.ONI'ROL BOARD C/o S.W.F_HP.S. DA'T'A PROCESSING(.'ENTER P.O.BOX 527 PARAMOLINI',CA 90713 0 0