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IN";I'RIJCIION,S FOR IMS IAINARM'A'
<br /> GFI�WIRAL INSIRUMONS-,
<br /> 1. One FORM"A"shall be completed for all NFW PF IN,PERMrI'CIIANCYF-S or any FA(M1IY/,Sr1E
<br /> INFORMNHON CHANGIN.
<br /> 1 SUBMrr ONLY ONE(I)FORM'A"for a Facility/Site,regardless of the number of tanks located at the site..
<br /> 3. This form Should be completed by either the PERMI'I'APPLICAN17 or the LOCAL AGEN(771f UNDEIRGROUNDTANK
<br /> INSPIN-MR.
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3 copies.
<br /> 'MP OF FORM: WARK ONLY ONE IMEM'
<br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed.
<br /> E. FAC1111Y/S1717131 IMURMAIION ADDRESS(MUSIAIF wMPI-Ftu))
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> N(YFEAddress MUST have a valid physical location including city,state, and zip code,
<br /> P.O.BOX NUMBER ARE NOT AMWABI-E
<br /> Include nearest cross street and name of the operator.
<br /> 2,'. Phone number must have an area code. If the night number is the sancta,write"SA IF" in proper location.
<br /> 1 Check the appropriate box for TYPE OF BUSINESS OV NEIRS1111" (c K, CORPORATION, INIAVIDUAL,etc;)
<br /> 4. Check the appropriate box forTYPE OF BUSINF-SS. N
<br /> S. If Facility/Site is located on land within an Indian resemntion or other indiin trust lands,check the box marked 'YE,'5".
<br /> & Indicate the NUMBER-oTTANKS at this SITE
<br /> 7. Record the EPA, 113 # or write"NONE in the space provridcd.
<br /> It. PROPERTY OWNER INIURM1i 11ON&ADDRUN(MUSr BE COMPlIn-ED)
<br /> 1, Complete allitems in Inis.4;ection. unless all iftms are the simo.as SEM ION 4.: if they w
<br /> same, •rite, 7&AME AS SVtIT'ackoss-
<br /> this section,I Be sure tc check PROPERTY OWNERSIllf"I'Y1 IE b6x,
<br /> 11I.TANK OWNER INFO RMN.-TON&ADDRn%(MUSF fit-, 00MITMED)
<br /> 1, Complete all hems in this section, unless all items are the sanic as SIs(710N 1; If the same,write "SAME AS SnT!
<br /> across this section. Be sure to check TANK OWNERSHIP'l-ePE box,
<br /> IV BOARD OF FQUAJJ7W110N USI'SIX)RAGE FIE1 AC(3OUNr NUMBER(MUST 311:COMPI If KIM).
<br /> Enter your M-)ard of Equalization (130F.) UST stor fee account rturnberv,,hich is required before your permit application can
<br /> be proessed. Registration with the will ensei,, at you will receive quarterly storage fee return in reporting•t he'Vi.000
<br /> 1'6 c The 1366-will code persons exempt from. paying the
<br /> rrills) �-ancm fee due or !be of e �',JaCe(] �u Volff
<br /> ot have
<br /> storaarc-Unt number with the BOF�or if Vou h.,we alo,questions
<br /> ge ns wili. nj
<br /> regard" -W, CXCr-
<br /> 'K: ,b,.. I(' 39-25Q,2 or write to the BOO at the following address: Board of
<br /> u a 1 L., cnqlnr,.. , I I Unit, CA 9,1279-(Ml.
<br /> to II,('A1,N M11710NTION AND 1311,11 JANG ADDRE,'Ri
<br /> 1. Check ONE BOX for the address that will be used for 13CMI 1,MAL AND B111 INN N(2'rMCA"014S.
<br /> APPLicAmr musrSIGN AND IWIT—DIR FORM AS INDR:A110,
<br /> INSITV X71ION MR'ITHE WCAL AGINCIF-1;
<br /> Thc county and jurisdiction nvrnbc-s' are prcdetcrrnirtcd and can be obtained by calling the State Roard (916)739-2421, The
<br /> facility number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the Stile Board to assign the facility number,please leave it,bjank.
<br /> rr Lsnw RmPoNsymury OFIIIIS LO(AL AGENCY iiuvr imspwisniE I-muiry'm yFRjFY,njE
<br /> (IN i AT' T"CANNO'll'BE PRO(T&SID IFITIR BOB ACCOUNr
<br /> I,Oi S MMPLIMON OF IIIE'LOCAL
<br /> N
<br /> Rt"; 6 11tj E FOR 1111,
<br /> �C'�(-Y I
<br /> Cl T IiVI C3
<br /> CS '4111 111 C-AL
<br /> -C
<br /> NC I ER,IS �0`1
<br /> C Il 1( 10 At IN( SSOCINI'M FORM
<br /> � "1'0 IY I I)
<br /> A U MA N IKOX NO I )R I RW i ONE FORM W AND A,
<br /> Ir(s)1-01HE F011,0WING ADDRI-W&
<br /> SrNIT
<br /> OF CALIFORNIA
<br /> ,71WIE WNIER RF-SOUR(-'F-%CONTROL BOARD
<br /> C/o S.W.1-1aps,
<br /> DXI'A PROCTSSING(F 'R
<br /> P.O.13OX SZ7
<br /> PARAMOY `A 90M
<br />
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