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M-4-
<br /> IMSI'RUCYIONS FOR ('(WITI-I'l ING FOPM 'A'
<br /> GENERAL 'MJ'RUCOONS:
<br /> I ("'W"! "-A", 'll,lil he (-nnp!,-tccl for all Nl,:-Xi[ PFRMITS. PEIRMI I' CIIANGFN of im FA(:II,lTY/'lI I F
<br /> ONIA OINE' (1) FORM "A' loi i i "t
<br /> the I W;%I. AGI;NCY I'M)l N't)
<br /> r Inn mwtlO kc by clth,:r lite
<br /> t'1 i2 APPLICANI'
<br /> 1Z
<br /> <
<br /> TOP OF FORM: RK ONLY ONI I 11 AV
<br /> \I,Iik III thcllc�l l ' cm that best dc,;,rilc.,, the ,cason II)c 1,) I,l rl ''cin, c-lIllik Tf,
<br /> ' :ho a1.
<br /> 1. FA('HITY/SrIll INFORMATION & ADI)RHNS Cy" Sr 10; COM111,1411))
<br /> t. IZ,(io)I-,1 11,1[11caw;l addreas (PhYst"'If lo"Itiol,I of the llndclgl,>Uln,-,
<br /> II valid ptlys;"afl lo',allim inrilillhilt
<br /> P-0, BOX NUMIWItS ARE N61" ACCJYJABLF
<br /> Include lwa :t IIoss strcO 3!1,i the ,pcf-jj,)r
<br /> must have an arca c-0,, i, i!-11 mghl wlivI)f- in pi"ji'l
<br /> 3. Check the appropriate lio, tor -1 Y11F Ii, (cK, COP Ilk)P/\1 1()\, I I .
<br /> 4. Check the appropriate bo,, f,,r T�PF OF HII
<br /> If Facility/Site is located within 111 Indi'all rest c.kzlt s,r other IndianIndian11"viii 1'1ndthe ho\ (11:lrk,:J"
<br /> 6. Indicate the NUMBER of TllaVftiS -)I this ',I IF..
<br /> 7. Record the E.PA- ID # or write 'NOtiI-." in Ih,. '.pace rosir�ru.
<br /> H. PROPEWI-Y OWNER JIINFORMA:11701N& ADDRFSS (MUST BE COMPLE-n-10)
<br /> Complete all items in this section, unless all items arc tile same as SECTION 1; if the same, write "SAME AS SPIV'
<br /> this section. Be surc, to check PROPER) Y OWNI;RS11111 TYPE box.
<br /> W. TANK OWNERIN1,01CM-NEON & ADDRF,.S,S RE COMPLLMID)
<br /> Complete all items in this ,I�cii-:,, unless .H t:,c same as SECTION I-, If the M11
<br /> this section. Ile ;ijre to ch,:cl, I ANR OINI'aARS)PIP TYPE hov.
<br /> IV. BOARD OF EOUAi.IZ-NllON STORAIGE Ft,+' AC(_'OUNf' NUMBER (Mit-1,10' BF COMPIT-11'.1))
<br /> Enter your Board of Equalization (110Y) UST star ,,,c fee account number which is required W'OIC YOL11- [Wf-fflit
<br /> can be processed. RegistriAti0i) ""[III the 110F. ,,ill ensure that vou will receive a qll,'irteily storage fee [-CtLIl[l In I-Cr"i(jiling, tile
<br /> $0.006 (6 mills) per gallon fee (ILJb on flit number of gallons placed in ,vur L'`;I's- The Wit: will CI)dc C."cn)pI from
<br /> paying The storage fee so returns will iwt !-,(, sent, U -,,oil do not tinve an ac",c)(jIlt number with the W)l: of if \ud hJVC ;W�
<br /> questions regarding the fee or 'ah lhc 1, ;:q %IF;[(: to the Boi ;1t Ilic C''lioww't',
<br /> Board of Equalization. Fn�'rrornv-,iv;d :ucs Lrii PJ). 1,-- i9. 1 Liov nio.
<br /> V. PETROLEUM U,%f FINANCIAL R17-SPONSIBB-171-Y (MUST BE COMPLFIT;D)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibiljt}
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> Vt. LEGAL NOTIFICATION AND 1311.11ING AD:)RF-SS
<br /> Check ONE BOX for the address that will he used fur 13 Y111 LLrjAJ. AND BH.I1NG Nort'll'ICNI[IONS,
<br /> APPLICANT MUST SIGN AND DKIT THE FORM AS M10VI1q).
<br /> INS-IRU(M. ON FOR'11TILE WCAL AGENCIES
<br /> and r.irisdiction numbers are snd can he li%, calling, the State Board (916")739-2-4-11, PIC
<br /> f,willtv rn.a5- he assigned by the ictal ngeliq: hiiwcvcr. this mwnhcr nwi>i he nunwrical and cannot ct)nrairt an,
<br /> It Mire 1,)Cuj 1-;TfffCjs !hi- P(-,alkl t, assi'll) [lie millib'.1% rlcaNc leave it I'lank,
<br /> g
<br /> N, IS 'jilill 10,*.SFON'1-1131111'Y OF'1151i ',(C':NCY THAT INSPF(TS '11111 FAC 1111-Y TO VI-Atfl--Y'nW.
<br /> AC(J-J"(-.Y 011HW INFORMAIION. THIS W,kiloN, C,1,NNOT BF 111"OCESSED IF ITIE DOE ACCOUNI'
<br /> N(1`-,l I'll,"R i8 NNOT 111.1 1''13 1 N. '11W LOCAL A(;ENCY IS RNSIIONSIHIJFOR 11W COMPLETION OF mE
<br /> 'D)(-AL AC',EN7CY USF QNI-Y' INFORN4AITON WX AND FOR FORWARDING ONE FORM W AND
<br /> ASNOCIAT91) lk)I(Nii "It"(s) TO 11W FOLlf)WIN6 AI)DRF-C's,
<br /> ,1-IWI I3 OF CALIFORNIA
<br /> SIATF WA114t RF-SOUR(T.S CON`1'RGJ. BOARD
<br /> C/o
<br /> DNFA PRO(TS-SINO (TINJIT
<br /> P.O. BOX 527 3�
<br /> PAPUtMOUNF, CA 90r-3
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