|
IN.SIRUCIIONS FOR C OMPLA FORM'A.
<br /> GENERAL IN9IRUC11ON&
<br /> I. One FORM "A" shall be completed for all NFW PERMrIS,PERMrl'CIIANGES or any FACILIFY/SOV
<br /> INPORMA'IION CHANGES.
<br /> 2. SUBMrr ONLY ONE(1)FORMA'for a Facility/Site,regyrdlcm of the number of tank, Ioeatea at the :so
<br /> 3. This form should be completed by either the PF,RNIM APPLICANT of he I--)(A1.AG NCY `.„NK
<br /> INSPP("TOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument, you are making.3 copies.
<br /> TOP OF FORM: 'MARK ONLY ONE rIEM'
<br /> L Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACIIJIY/SrIF INPORMAITON&ADDRESS(MUST BE C OMPIdSIB))
<br /> 1. Record name and address (physical location) of the underground tank(is).
<br /> NOTE Address MUSI'have a valid physical location including city,state, :cod ,.ip code.
<br /> P.O.BOX NUMBER ARE NOT A(YTIFFABLI?.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number most have an arca code. If the night number is the same,write "S,AMF" in proper !—'L,on.
<br /> 3. Check the appropriate box for TYPE., OF BUSINESS OWNERSHIP (c.s. COKPORA 1 V)N, F:OIs IfICAi_ elk
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located on land within an Indian reservation or ol�iin Indian trust birds, check the box marked "YFS"
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the F.P.A. ID # or write "N(`\P" in the space provided.
<br /> 11. PROPF:R'IY OWNER INFORMATION&ADDRESS(MUSI'BE COMPLu1-D?D)
<br /> L Complete all items in this.sectwn, unics> all items;are the.came as SE,(TCON ); if the same, write '.SAME AS SITE_ 'across
<br /> this section. Be sure to check PROPERIY OWNERSini, n11 box.
<br /> BI.TANK OWNER INPORMA'11ON&ADDR1,SS(MUSI'BF COMPI E[11))
<br /> 1. Complete all items in thin section, unless all items are the same as SI'.(71ION 1; If the same,write 'SAMF AS SHE'
<br /> acttw this section. Be sure to Check'LANK OWNL'RSIM-1YPI:box
<br /> IV BOARD OP IQUAIJZA11ON USC S`f`Of GE FIM ACCOUN?'NUMBUR(MUSI'131;COMP1,151m)
<br /> Enter your Board of Fquahzaiv,ii (Bt)F) USI'storage tee a,,c,,nr nr.nther whirl, is rcgtdred heron, your permit application can
<br /> he processed. Registration wi,h the BOF,will ensure that you will receiveI quarterly storage Ice return in reporting the 1110(16
<br /> (6 mills)per gallon fee due on the nomhr.of gallons plecea n .knur PST's. 'Ilse Fv iE vall Code persons exempt from p:rvmg the
<br /> storage fee so returns will not he seal If von dr not have a rc,r n• n m�'•cr with the BOL or if,-ou h gcestvr,.
<br /> regarding the fee or escm.Riorsplease d the IiOr + lit,'3r?5il .r,rile t,, the 1301'at the I,flowing ,ldresc IAlarcl of
<br /> I qualizariou, Fnairomnental F1-s Unit. 1'.O. Box 91'S79, Sacramento, (;A r%I?71tfHY)1.
<br /> V. 1J GAL NO'IIIICA`DON AND 131I1JNG ADDRESS
<br /> L Check ON13 BOX for the iddress that will be used for 13(rTII IWAL AND BILLING NOIFIFIE(W110NS.
<br /> APPIJ(:ANI'MUST SIGN Am)DATTI'1111I FORM AS INDICATED.
<br /> INSPRUC11ON MR THP,LOCAL AGENCIES
<br /> The county and jurisdiction nu-nhcrs are predetermiied and can tic obtained by calling the State Board (916)739-242L The
<br /> facility number may be assigne.l by the lo,a] agcnep; however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the SL;ic Board to assign the facility number, please leave it blank.
<br /> rT 15171E RPSPONSIBB.rrY 017'1111?LOCAL AGENCY T'IIA'1'INSPECTS 111E FACBJ'IY TO VERIFY'11IB
<br /> ACCURACY OP'n IP iNFORMA11ON. 1111S APPLICATION CANN(71'BE PROCI'SSFD IF771I1 BOP ACCOUNT
<br /> NUMBER IS NOT FILLED IN. '111E 11XAI.AGI?N(Y IS RI?SPONSIBI.l!hOR T111?COMI'IJFIION OF 111f?'1.0(i1L
<br /> AGENCY USE ONLY'INFORMA"IION BOX AND FOR FORWARDING ONE FORM WAND ASSOCIATED FORM
<br /> "B'(s)'PD'11111 FOLLOWING ADDREtiS.
<br /> S17VIE Of CAIJFORNIA
<br /> SI'A"IE WA'W.R RESOURCI3S CANIROL BOARD
<br /> C/O S.W.ELP.S.
<br /> DATA PRIX'ISSING(WEER
<br /> P.O. 13OX 527
<br /> PARAMOUNT,CA 91]l
<br />
|