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INV • i INSTRUCTIONS FOR COMPI.ERING FORM "A" GENERAL INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERMI S, PERMITT' CIIANG1;S or any FACiLr1 Y/sf11? INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the site. 3 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDI;RGROLJND TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copi,:s. TOP OF FORM: "MARK ONLY ONE ITEM" Mark an (X) in the box next to the item that best describes the reason the font is,.being completed. L FA(7LITY/BYTE INFORMATION&ADDRESS(MUST BE COMPLEIEi)) 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 ACCFPrABLIL 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'T'ION, INDIVIDUAI.,, 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 bot marked "N't's". 6. Andicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or. write "NONE" in the space provided. II. PROPERTY OWNER INI-ORMATION&ADDRESS (MUST BE COMPLE'110) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME AS Sr1V* across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLEilw) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS Srl'F.' across this section. Be sure to check TANK OWWJWIIP TYPE box. IV. BOARD OF EQUALIZATION.UST STORAGE FEE.ACCOUNT NUMBER(MUST BE COMPI.F..I71)) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOB 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 USTs. The BOB 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 BOB or if you have—any questions regarding the fee or exemptions,please call the BOB at 916-323-9555 or write to the BOB at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento; CA 94279-0001; V. PETROLEUM UST FINANCIAL RESPONSIBII,TTY (MUST BE COMPLEWD) 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 N(7ITFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING N0(I717C:NI70NS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENC3ES 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 THE RESPONSIBIU Y OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY'TIIE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THLr "CAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O SW.E.E P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723