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<br /> GE'NERAL E I,Itd4!"TIUMONS.
<br /> 1. One FORM"A"shalt be completed for all1£. 1 ERM)"[s, I'"CHANGES or any FrAo t""y/srim
<br /> INIFORMAMON MANGES.
<br /> 2 SIJBMrr ONLY ONE 1)FORM*A"4;b a Facility Site,rega less of the:number of tinks located at the'site,
<br /> 3. This form shovicd be completed by eitheC.tbe I'EB,\fd I' PPIJC',. N1'car the. tW.PlL AGENCY L7IadDI?itt33tt1UND TANK
<br /> INSPF.CrOR.
<br /> 4. Please type or print clearly al(requested information.
<br /> 5. Use a hard point writiaig instrument,you'are making 3 copies.
<br /> TOP QF F(:3 . *MARK ONLY GNE TIMM*
<br /> ( )Wtftc kho�'neat to the 'tt s tlsac t est describes the reason the form is being completed,
<br /> 1. FAC111-Y/Srf" NFORMYi'ITON0. 13 &.4 Wim"BE ,sl y
<br /> 1„
<br /> Reret name and iictclrc '(pfs icat"7cx at�sn)of t e isttctc:rgrt�asrtdtank(s).
<br /> SXYIx : Address S'It.,S'F have a valid physical location including city,state,and rip code,
<br /> P.0) 130NUM:1I:?It ARE NOrr ACC ? ABI.1?
<br /> Include nearest cross street and name of the operator.
<br /> 2, Phone number nitist have an area ccAe, If die night number is the same,write'S ff"in proper locatiom.
<br /> 3. Check the appropriate box for°I"'4 P 01`BUSINESS OWNERSHIP (ex.C;EIRPO I'lO'v, INDIVIDUAL, cake)
<br /> 4< (,hack.the appropriate,boix for'[-YPE.OF BUSINESS.
<br /> 5. If Facility/Site is located on lance within in Indian reservation or outer Indican trust lands,check tic:box marked"'YL_S".
<br /> 6. Indicate tha NUMBER ofTANW3 at this SITE
<br /> - 7. Record the EPA,I1)4 or write "NONF," in the space provided,
<br /> 11. PROPH11CFY OWNER INFORMMION&ADDRESS a Ri!,cOMPI,L?`17I11 )
<br /> 1. C;anapk-s all items in thisleder t, atnless all items are the:Sam a,"SF(,"t iON 19 if the sarne,unite'SAME AS S1"I "across'
<br /> this section, ?3i:sure to check P:aI(I'LMFY )W l' FIN'SHIP°I SPIT;box,
<br /> 1.. Ill.TANK 1W I,R INI°aORIMd'4TIoN&ADDRE&S(. .I.)N'Bl"MWIX11a))
<br /> i`
<br /> 1. C air plate all ate rns in this section,awnless all items are the same as ;F C]'IO'1 li if the wane, write'S :o S SMIE
<br /> across this section, r c, sue to check TANK ONFiiSII P TYPE bo e.
<br /> 1V ROAM')OF I"1U 1,1'PWI ON Ii "I' T'0RA(;F 1'T?I? (,N4U,,;FBnCiot I>Tb1nvm)'
<br /> e
<br /> c,r A'u !colt d of 3lquktaizcii.>i (WE) US'F storage fee accoul-It number,Which is mquiHed before your permit application can
<br /> ie proressed. 'Registration with'te.i;BOE will ensur: that ter will receive a r saderly stcca e cue return in reporting the S0.006
<br /> (t,mil'=s) per,gahon fere due on the taaimbeir of gallons, placrad in cluz L,ST"i. 'l l e Iii E will code persons exempt from payui� the
<br /> t,t,+.z e7g„ ie,:,Sb3 5s:,eE.27?`will r7i)#; be St;?7 t. It 4<'s2t F€Lt itE"?t have an account 3?t?n1l?£',t'a7th t,
<br /> ,he B01`or if you Have any questions
<br /> v .:arabng the fee or cxcntptioas, pa eaie tall the B01 to 916-7739-2582 or w°rita to the 110 at the following addr€€s. Board of
<br /> I c wxaliraHon, Flwrironi caul heel;Unit,11.0. Box 942879,Sacramento, CA 94279-000-1,
<br /> V.
<br /> 1. CheckONEWOX for the address haat will be used for 13C3'1Tf.I T.r ib AND DIMING &I'11g(Wl 0NS;,
<br /> INET )C1,'1t'sN FORME`ITI{LOCA e AC:MINI CIPS
<br /> The county and jurisdiction numbers'are predetermined and can be obtained by catling the State Board (91')739-2.:421. The
<br /> au£.i ity r1ur?ber may be assig„ed by tike 3€ al agency-, however, this numbt number must be numerical and Cannot€afl chain an alphabet. If
<br /> the, local agency prefers the State Board to assign the fatality number,please leave it blank.
<br /> rr,.LS"1°imzEFPO:3 IBII Y (W1111,"LOCAL FACIM'Y`l-O'VERIFY'I"I3
<br /> At7h-Mf1$?gsC Y OF'17I11 '17115 PPLI(: '1'ON C tell(BE PROC.1i-`ISFI)IF 1111 13,0 11 ACCOUN17
<br /> U BE IS;l (3'I'FILLE ISI. THE LOCAL AGENCY IS RaSPONSIBIJT IAC} `1111},COMPLIMON()Ir 1 1E"IC)C`AL
<br /> AGENCY USE;INLY. INFORMN110N I3OX AND FOR FORWAR1?IN ONE FoRM,"t"V AND SSOC'T ``t AT-) 1-0IM
<br /> W(s) °hI" E POIL(J vTi$'d'G DDRE&S.
<br /> S'rxI ,OF CALIFORNIA
<br /> ti 1"rs°1 T:WATER RE, 1I RC: C".OWIZ(N,BOARD
<br /> C/0 iMF-ILPS.
<br /> MVI'A PROCESSING C ENIER,
<br /> P.O13O527
<br /> PARAMOtINT,CA a
<br />
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