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<br /> IN,%RtJ `I10NS FOR COMPLI-q7ING IFORM W
<br /> GENERAL IN,91RU(711ONS-
<br /> 1. Gate FORM "A' shall be completed for all NEW mutmnNs, PERM FF blANGES or "InY FACILITY/St'l F
<br /> INFORMYVITON CHAN60S. "NIN
<br /> 2. S'UBMI'T'ONLY ONE (1) FORM 'A" for a FacilityPSite, regardless of tile of tanks totaled �11 Ih,, si".
<br /> 1 Thi, or -Y I-1-NDI;.R6R0!1ND
<br /> a form should be completed by either the PERMIT APPIJCAKI [he �WAL AGENC
<br /> TANK INSPEX71'Olit
<br /> 4, Please type or print clearly all requested information,
<br /> 5, Use a bOrd p0iN Writill"I HistrUnlent, YOU are making 3 copies.
<br /> 'FOP OF 11OW& 'IMARK ONLY ONTE rIT,M"
<br /> Mark an (X) in the box next10 the itenviliat best describes ibc reason the form is being compicted.
<br /> I. FAC-11TIT/Sn-F INFORMKITON & ADDRIM MUS I'134 COMPIJUED)
<br /> L, Reepril nanic and add�t;ess (physical location) of the underground tank(s).
<br /> NOTE:' Address MUST have a valid physical location including city, state. and zip code.
<br /> P.O. BOX NUMBERS ARE: N(Yr AC0.717ADIn
<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 same, write ISAMF," in poiler location,
<br /> 3. Check the appropriate box for TYPE O' BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.)
<br /> 4. Check the appropriate boxfor WPF, OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands. check the box marked "YFIS",
<br /> 6. Indicate the NUMBER ofTANKS at this srrE.
<br /> 7. Record the E.P.A. 11) # or write "NONE" in the space provided,
<br /> IL PROPEW.1-Y OWNER INFO I` &ADDRESS (MUST` BEcomilt un:,I))
<br /> Complete all items in This section, unless all items are the same as SI`(-.TION L, if the same, write 'SAIME.AS ST'I'R" across
<br /> this section. Be sure to check PROPERFY OWNERSHIP TYPE box.
<br /> M. TANK OWNER INFORMN.110N &ADDRESS (MUS`F BE COMPLFITD)
<br /> Complete all items in this section, unless all items are The soums SE(")'ION 1; 11' the state, write 'SAME. AS SITE across
<br /> this section. Be sure to check- TANK OWNE-.R.S1ITP'I`YI1E, box.
<br /> IV. BOARD OF EiQUAIJZAI1ON U51'STORAGE 14Hi ACCOUNI'NUMBER(MUsr Be coMPTITIT'j))
<br /> Enter your Board of Equalization (130F) USI'storage fee account number which is required before your permit application
<br /> can be processed. Registratic)n with the BOE will ensure that you will receive a quarterly storage fee return ill rcporling the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UTST.s. The 130E will code persons cxempi floill
<br /> paying the storage fee so returns will not be sent. If volt do not have an account number with the BOF or if vou hAve any
<br /> questions regarding the fee or exemptions, please call the 130E at 916-323-9555 or write to the 130E at the followino address:
<br /> Board of Equalization, E'nvironniental Fees Unit. P.O. Box 942879, Sacramento, CA 9,1279-0001.
<br /> V. PIzTROl.J,71UM usr FlINANctAlt. RF:SPONSIDI-LrrY (MU,';,r BE COMPLE-11,D)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> VL LF(;AL NO'11FICATION AND B1111ING ADDRESS
<br /> Check ONE BOX for the address that will be used for BO`l'II LF(IAL AND 131111NG N0rnIqCKnONS.
<br /> APPIJCANI' MU,91SIGN AND IWIM'11114 FORM AS INDI(WI19).
<br /> INSTRU(TI1ON FOR 111E LOCAT—AGENCiS
<br /> 'Khe county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)7.39-24*21. 'file
<br /> foicOity number may be assigned by the local agency, fc0WCVeT, lt7tiS VIL1111her n1USZ Ile numerical and cannot contain anv
<br /> alpli,ilbetical. If the local agency prefers the State Board to assigns the facitity number. please leave it Wank.
<br /> n,IS OF 11W LOCAL AGENCY THAT INSPECIN'11JU FAC'11,171'Y TO VERWY '111E.
<br /> ACCURM"Y' OF INFORMA110,N. '1111S AIT!J(,`1;10N CANNOTBE PROCH13SED II'"111E BOE AC COUNF
<br /> NUMBER IS NO!' 1,11LE11) IM HW LO(AL AGENCY IS RESPONSIBLE, FOR *11JE COMP11MON OF ITIE
<br /> 'LOCAL AE F)WY US ' ONLY' I JON BOX AND FOR FORWARDING ONE FORM "A" ANI?
<br /> ASS,00AIIJ.) FORM "B"(s) '.1'0 F011,0WING AD13RENS.
<br /> SI'MI'll OF CALIFORNIA
<br /> STXII?WMER RESOURCT.S (DWROT, BOARD
<br /> C/o S.W-Fulx-&
<br /> DATA PROCESSING CEMMR.
<br /> P.O. 13OX 527
<br /> PARAMOUNI7, CA 90723
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