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- :. . . INSTRUCTIONS POR COMPI.H1'ING FORM'A" GENERAL INSTRUCTIONS: 1. One FORM "A"shall be completed for all NEW PERMITS, PERMIT C UANGESS or any FACILITY/SRL INFORMATION(TIANGFS. 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 APP11CANI'or the LOCAL AGENCY UNDERGROUND TANK INSPF.(71Y)R 4. Please type or print clearly all requested information. S. Use a hard point wriling instrument,you are making 3 copies. TOP 011 FORM: 'MARK ONLY ONE ITEM, L Mark an (X) in the lint"next to the hem that best describes the reason the form is M1ung completed - I. PACTId1Y/SIL INMRMATION&AbDI1E+SS(taUSf'311 L'OMPLEI'ED) - •—1 - 1 f`� '\ , 1. -Record name and address`(Ohy3ical)ocalion)of the underground tank(s). ' NOTE: Address MUST have a validys' g cit h teal location including 't p y,state, and zip code. P.O. BOX NUMBIM ARE NOT ACQ71'ABII? Include nearest cross street and name of the operator. ? Phone number must have an arca code. If the night number is the same, write "SAME:" in proper location. 1. t, 3.. {{hqq a ro riatc,box for TYPE OF BUSINESS OWNERSIIIP (ex. CORPORATION,INDIVIDUAL,'etc.) 4\^ c�`lNeSappropriate box for TYPE OF BUSINESS. 5. If acility/Site is located an land 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 IiT.A. ID # or write "NONE' in the space provided. '.B, PROPERTY OWNER INPORM/VI'W J•.&.AI)I)RL'SS.(`M{1Sr BE C(.ZMPI:Eruff ' 1. Complete all items in this section unless all items are the same as SECI[ON-1: ik thatisamc.write .SAM E.AS SSPE"across this section. Be sure to check PROPERTY OWNER-4j,10 TYPE bo 1 t _ IB.'1'ANK OWNER INFORMATION&ADDRUSS(MUSE BE COMPISi17iU) 1. Complete all items in this section, unless all items are the same as SECEION 1: If the same,write "SAME?AS SITS'." across this section. Ile sure to check TANK OWNERSHIP'IYPE box. IV BOARD OF WUAIIlA'IION USP SPORAov FEE ACGQUNr NUMBE R q _411,tFr BE LY)MP1,I31IF3U) t , Ente{your�oaM of Equalization (130E) US1'storago fee account number which is required before'your permit application can. kpTse�, egistratiott t}t,tlr�dll(2 will ettadrV that you will receive a quarterly storage fee return in 14ltotting the S(ywo"' _ (6 mills) per�ahon fce due'on'& nurhtier of gallons placed in your USTs. The BOE will code persons exempt front 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 BOL.at 916-739-2582 or write to the BOE at the following address: Board of I_qualization, Environmental Pees Unit, 11.0, [lox 942879, Sacramento. CA 94279-0001. V. LEGAL NOTIFICATION AND RILING ADDRFSS " ' ✓ x:J--� r� -1.' '. . I. Check ONE BOX for the address that will be used for P(YRI MGAL AND BILLING NOT7FICA'IIONS. APPLICANT MUST SIGN AND DATL'TIIE FORM AS INDI(ATfID. INSIRUC.ION FOR TILE LOCAL AGmCIECS The county and jurisdiction numbers are predetermined and can be obtained by calling the Stale T3oard (916)739-2.421. The facility number may be assigned by the local agency, however, this number must he numerical and cannot contain an alphabet. if the local agency prefers the Slate Board to assign the facility number, please leave it blank. h-JS 1TIE RP_SPONSIBIISIY OF TI E LOCAL.AGENCY ITIAT 1NSTl?CES 111E IrACILIY"I'O vERIFY'TIIE ACCURACY OF'I1B3 tNI7OFMA'I70N. TIIiS APPLICATION CANNOT BE PROCI:I_SSF.D 111'1711? 130E AC(Y)UNI' NUMCIER IS NOT FILLED IN. 1711.LOCAL AGENCY IS RI:SPONSIBI.E FOR Tl1E COMPI]3TION OF T7IFI'IA(AL AGENCY USE ONLY'INFORM)MON BOX AND FOR FORWARDING ONE FORM "A'AND A.SSOCIAIIIU FORM 'B'OO TO THE POILOWING ADDRL'SS. ( ,` S: SI+A 11[3 UT)�CAT: R)VIA SPATE WA'ITIR RESOURCES CONTROL BOARD C/O S.W.CLPS. DATA PROCP.%TNG CENTER P.O. BOX 527 PARAMOUNT, CA 90713