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—tt!�Ot-TP.�+gfAr�!fr,-�`rw'+iS.Ff1�"�v!p7"' T7Ca"�a�r .-..ae.,,,-�.r..-y�,•�,R INSTRUCTIONS FOR COMPLETING FORM "A' GENERAL INSTRUCIIONS: L One FORM "A" shall be completed for all NEW PERMITS, PERMLF CIIANGLS or any FACBd1Y/31'11? INFORMAIION (MANGES. 2 SUBMIT ONLY ONE (1) 17ORM "A' for a Facility/Site, regardless of the number of tanks located at the site. 3. 'this form should be completed by either the PERMrF APPLICANT or the LOCAL AGENCY UNDERGROUNI) TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. 'POP OF FORM: "MARK ONLY ONE THEM" Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACu.rIY/sR'E INPORMA"IION& ADDRESS (MUST BE COMPLE1731)) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACCEPTABLE. 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. CORPORATION, INDIVIDUAL. etc.) 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.Y.A. ID # or write "NONE" in the space provided. u. PROPERTY OWNER MPORMNJDON&ADDRESS (MUST BE COMPL.ErED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME:AS SFIE" across this section. Be sure to cheek PROPERTY OWNERSHIP TYPE box. III. TANK 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 Srn-';, acro,, this section. Be sure to check 'TANK OWNFRSIUP TYPF box. BOARD OF FQUAITLATION USI'STORAGE FEE ACCOUNT NUMBER (MUST BE COMPLE1733) Enter your Board of Equalization (BOE) UST storage fee account number which is requited before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's. The BOE will code persons exemptfrom paying the storage fee so returns will not be sent. If you do not have an account number with the BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-3219555 or write to the BOF; at the t'ollowing address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento. CA 94279-0001. Y. PErROLP.UM UST FINANCIAL RRSPONSIBIU Y (MUST BF.(-DMPI,L•TFD) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. US"rs owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE, BOX for the address that will be used for BOTH LEGAL AND BUIING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR TIB? LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 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. IT IS 711E RrSPOM9B11S1Y OF 1TWLOCAL AGENCY THAT INSPECTS THE FACIISIY TO VFERWY'i'HF. ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE DOE ACCOUNT NUMBER IS NOT FILLED IN. 711E LOCAL AGENCY IS RESPONSIBLE FOR 711E COMPLETION OF 711E LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "B"(s)TO TIIE FOLLOWING ADDRESS STA7I? OF CALIFORNIA STATE WA'TE'R RESOURCES 0ONJI'ROL BOARD C/O SW.E r Ps. DATA PROCISSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 0 •