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'NSYRUC31ONS FOR COMPLETING FORM W
<br /> GENERAL INS TRUCHOM.
<br /> L One "A' shall be completed for all NEV PE -S, PERMIT CTMGM_ or any FAC1Lrl'Y/SrW
<br /> 2, SIJ BMfF0N`r'h_ ONE (1) FORM *A* for a Facility/Site, regardless of the number of tanks located at the Site.
<br /> 3. This form ;,)e completed by either the PERMIT AP1111CANT or the LOCAL AGENCY UNDERGROL)ND
<br /> TANK INSIIFA `OR_
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument, you are making 3 copies.
<br /> 7X7P OF FORAC 'MARK ONLY ONE ITEM"
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACI1_X1-Y/,SrM HOORMN11ON&'ADDk R%'(mv87r'nE compusirb)
<br /> I.'-, geZord name and address (physical location) of the underground tank(s).
<br /> NO`17. Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. 13OX NUMBERS ARE NO`r ACCIYJABIF-
<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 "SAME" in proper location,
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORAIJON. INDIVIDUAL, etc,)
<br /> 4. Check the appropriate bbx for I-YPE OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES'.
<br /> 6. Indicate the NUMBER of"TANKS at this SITE.
<br /> 7. Record the E.P.A. ID # or write 'NONE" in the space provided.
<br /> PO
<br /> TIONADRE,% (MUST BE COMPM-rFD)
<br /> Y OWNER ON & D
<br /> R-WORMA PP i TFF
<br /> Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME. AS S1711' across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> U1. TANK OWNER INFORMATION &ADDRMNS (MUST'BE COMPLEWID)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS Srll* across
<br /> this section. Be sure to check TANK OWNERSIRP1YPE box.
<br /> IV. BOARD 01F()IJAY17ATION.UFFSFO PAGE FFE ACCOUNT NUMBER(MUST BE COMP111111ED)
<br /> Enter your Boiird of Equalization (BOP) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> %006 (6 mills) per gallon fee due on the number of gallons placed in your U91s. The BOE will code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BOE oi- if you have any
<br /> questions regarding the fee or exemptions, please call the BOF at 916-32.3-955S or write to the BOE at the following address:
<br /> Board of Equalization, Environrnental 1:,ecs Unit, P.O. Box 942879, Sacramento, CA 94279-0001.
<br /> V. PE'IROI1,fUM UST FINANCIAL RESPONSIBUITY (MUS-r BE COMPLffM:zD)
<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 /> VI. ll:,,GAI, NOTIVICA71ON AND BILACiADDRESS
<br /> Check ONE BOX for the address that -,.Vill be used for B(.Yni UXiAL AND BHANG NO'WI(WnONS.
<br /> APPLICANT MUST SIGN AND DAFE THE FORM AS IMN(WIED,
<br /> INSI'RUCIION FOR`I LOCAL AGI3NC11ES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The
<br /> facility number may be assigned by the local agency, however, this number must be numerical and cannot contain any
<br /> alph,letical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> FFIS TTIF kFNI'ON'1t 0oXI-Y 01-1711i LOCAL AGUNCY 'ITIATINSPECT'S'111E FACIIJTY TO VERIFY11111
<br /> ' j � . -10 TIRS A111"Lli,"NiJON CANNOT BE PROCF_�SED IF1711Y ,1, A 'CO JN
<br /> ACCURACN 01, 11P, 'N"l; 4,�VIIONI . i B0 t I
<br /> NTTMBFR)N FIIA 11"'D IINL '1111, 1,00M,AtMNCY IS RFNPONS113114 FO.R'111E COMPLE'fTON OF711t,"
<br /> "110CA!, :ACIFNCY USE ONLY' INPORk4A,1T,1N BOX AND FOR FORWARDING ONE FORM 'A" AND
<br /> ASSOCIA114) 14ORM 'B(s)1-0 'ITIE F-(;.3 Ow-ING ADDRESS.
<br /> 'MXJIr OF CALIFORNIA
<br /> WA'11iR RESOURCIIN CONI'ROL BOARD
<br /> C/0 S,.tk3Z_1LPS,
<br /> DAT.,"kK(,K7E&' SING CEKI1,,*R
<br /> P,0. it-01,
<br /> PARA M0(dN;I_'1 CA 907-73
<br />
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