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-4- INSI'RUC711ONS FOR COMPLETING FORM "A! GENIMAL lN,'3'I'RUCJ.'IONS-. On,,- 1:01'M 'A" sh ! be completed for all NEW PFRMfFS, PERNin,CHANGES or any IN'l'ORMA!IiON CHANGES. 2. SUBMI[T ONLY ONE(1) FORM *A" for a Facility/Site, regardless of the number of tanks located it the sit,-. 3. This form should be completed by either the PERMIT' APPUCANI'or the LOCAL AGENCY tJNI)I;R(;IZOLJNI) TANK INSPECTOR. 4. Please type or print clearly all requested information. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM. 'MARK ONLY ONE ITEM" Nlark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACILrI-Y/SrFF INFORMATION& ADDRESS (MUST BE COMPLITFUD) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, statc, and zip code. P.O. BOX NUMBERS ARE NOT ACCEWABIlL 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 "SAN11-1-" 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.P.A. ID # or write "NONE" in the space provided. H. PROPERTY OWNER 94MRMNI7[ON& ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 11 if the same, write 'SAME AS SPIV across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. HL TANK OWNER INFORMAT]ION &ADDRESS (MUST' BE COMPTInIED) Complete all items in this section, unless all items are the same as SECTION 1: If the same. write 'SAME AS SrI7' across this section. Be sure to check TANK OVINEWSHIP'l-YPE box. IV. BOARD OF EOUAIXI-AIION UST STORAGE FEE ACCOUNT NUMBER (MUST BE compuma)) Enter your Board of Equalization (BOE) UST storage fee account number which is required 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 BOF" 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 BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOL at the following address! Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-WOL V. PETROLEUM UST FINANCIAL RESPONSIBB1TY (MUST BE COMPLE31-1)) Identify the method(s) used by the owner and/or operator in meeting the l',*cdcral and State financial responsibility requirements. US'rs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTI[FICAT]ION AND BR1JNG ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BLUING NO`1114CATI[ONS, AmicAw mus'r SIGN AND DATETI[IF FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCtF-S 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 he 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 171E FWSPONSI[BUXff OF`nJE LOCAL AGENCY THAT INSPECTS 111E FAaLnY TO VERIFY nip ACCURACY OF'111E I[NMRMA711ON. T]IHS APPLICATION CANNOT BE PROCESSED IF 171E BOE ACCOUNT' NUMBER IS NOT FILLED IN. THE LOOM,AGENCY IS RESPONSIBLE FOR WE COMPLETION OF THE? 'LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCW11;D FORM "B"(s) TO 111E FOLLOWYNC Af-1;-)jWSS. STATE OF CALIFORNIA S`FKIT.WATER RESOUR(T'-S CONTROL BOARD c/O smiul-P-s. rJAJA PROCESSING CTWM.R P.O. BOX 527 PARAMOUNT, CA 90723