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<br /> INSMUCITONS MR COMPLEIING FORM 'A"
<br /> L, One I-CORM "A" shall he completed for all NEW PERMITS, VERmrr(31ANGES or any I1ACIIX1'Y/Srl17'
<br /> INFORMXYION CITANG04S-
<br /> 1 SUBMIT ONLY ONE (1) FORM *A! for a Facility/Sitc, r-,gardlc-ss of the number of tanks located at the site.
<br /> .1. This form should he completed by either the PERMIT APPMAMF or the LOCAL AGENCY UNDERGROUNI)
<br /> TANK INSPECrOPL
<br /> -;X,, or print clearly all requested information.
<br /> Llf-,, a hard point writing instrument, you are making 3 copies,
<br /> M,A—K ONLY ONE rITIM
<br /> "o,wk an (X) in the box next to the item-that-'best describes the reason the form is being completed.
<br /> T. VAC11XI-Y/SITE' INMRMNLION&ARDRESS (MU917 BE COMPIMI:D)
<br /> L Record name and address (physical location) of the underground tank(s).
<br /> ;VOTE,: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX NUIMBEKS ARL Mff r AC CEPTABLF-
<br /> Include nrar��.'t cross street arm name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORAJION, INDIVIDLIAL, etc.)
<br /> 4. Check the appropriate box for'I'YPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YFS".
<br /> 6. , Indicate the NUMBER of TANKS at this SrIT".
<br /> 7, Record the E.P.A. ID # or write "Ni,)NE" in the space provided,
<br /> IL. PROPER7FY OWNER INFO MON&ADDRE-SS (MU',';I' BE MMPLE'114.113)
<br /> Complete all items in this section, unless all items are the same as SE(T.I'ION I; if the same. write "SAME AS Sm., aci-0,ss
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> 111. TANK OWNER,INTO 'PION & ADDIWM (MUSE'BE COMPLUITD)
<br /> Complete all items in this section, unless all items arc.the same as SECTION 1: If the same, write "SAME;AS srn,'
<br /> this section. Be sure to check TAW. OVINERSHIPIWE box.
<br /> IV. BOARD OF WUAI.1ZJV1-ION F113 ACCOUNT NUMBER (MUST BE CoMPIrlla))
<br /> Enter your Board of'Equalization (BOE) UST storage fee account number which is required before your permit
<br /> can be processed. Rcoystration with the BOE will ensure that you will receive a quarterly storage fee return in rt,-o.;wg flIr
<br /> $0.006 (6 mills)per gallon fee due on the number of gallons placed it, your usTs. The ME will code persons cxempt fn)M
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BOE' or ifyou 11"I'Ve any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOFE, at the following nddrcs,:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001,
<br /> V. PI.-I'ROLEUM U.S"r MNANCIAL REMONSIMM X17Y (MUS-I'Bull COM1'IHIT--,I))
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> iLquircnients. UST's owned by any Federal or State agency are exempt front this requirement.
<br /> VI. LEGAL NOTIFICATION AND 11111ING A)DIENS
<br /> Check ONE BOX for the address that will be used for BOTI1 IJ,'.GAL AND BI1JJNG M-711111CA11ONS.
<br /> APP11(:ANT MUS`J'SIGN AND DA7M FORM AS INDICA7171).
<br /> IN91'RUCIION FOR'111F,LOCAL AGENCIE-S
<br /> Th, county a—,d jurisdiction numbi-r-, are ztnd can be notairied by calling the State Board (916)739-2421. The
<br /> fadivy nu"11N�r may be assigned oy :he local agency: however, this number must be numerical and cannot contain any
<br /> alphabetical. If the J()Ca; agenely the State Board to assign the facility number, please leave it blank.
<br /> 171 Is III U11''RESPON; kM'i1YJ'Y 0;-11IE LOCAL AGI!74(:Y 'ITINY INSPECTS—IIJE FA(-.1JJTY TO VERIFY
<br /> ACCURACY OF'PETE: INFO TION. '110S AppucATION CANN(Yl' BE PROCESSED IF'ITIS BOE ACCIOUNI*
<br /> bi� M
<br /> , ImBuw ;'s Nor IN. THE LO(LAL AGINC-Y IS RESPONSIBLE FOR 11114 COM1'LVnON OF -111.
<br /> *LOCAL A(;U*N(,,Y USE', ONLY' I.M-'ORIAA'IION BOX AND FOR FORWARDING ONE FORM 'A"AND
<br /> ASSOC11VIT'D MMM "1>'(s) Ti) -ME FOLLOWING AJDDRII-NS.
<br /> STAI 0' OF CAMFORINIA
<br /> 19111NIT' WA`rER RESOURC13S CONTROL BOARD
<br /> C/o Sviv.-I?Ps'
<br /> DA'I'A PROCESSING CF Tat.
<br /> P.O. BOX 527
<br /> MRAMOUVI', CA 7,23
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