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<br /> IN`sIRIX711O1xS FOR C'OMI'LL'i"IN6 VOR $A$
<br /> GENERAL INSJ'RUC'1IONS€
<br /> 1. Unc I°Cilz�i s ". sail be completed for all I I'I3[L, `3I PEsRMIT C1Ir4I GUN s;a ran°; FAVII ">'` �'-1 H
<br /> INFORMA 1.1ON CHAP3GUN,
<br /> s _ 2. 5 73 iI'I' 6a 1 k ONE (`t) Ia€3ldM * C °car tt �tl(t,}-f� ac".g:tlJ1,ss A ille nine Ser of 1 i€6:
<br /> 3. 1h form Sta+.e=id tic; completed l�y z€thcrthL 1'i I�'M APPLICANI of €ht LOCALA61"IINI-A t. irl'W ICtat.' til�
<br /> . , I ANS INSPEC"UOPL
<br /> 4. Please type or punt clearly all requcsled infonnedion_
<br /> 5• Use a hard point writing instrument, you are making 3 copies.
<br /> 1 C)P OF DORM- 'M- ARK ONLY ONE" rl' M"
<br /> 1'
<br /> Marl, an (X) in the box next to the item that best descaibes'the. reason'( c form is (stint; ronrPl:ted.
<br /> L F=Af.11IN/81`1T? I:' FORV2 XI'IO & h1:)1)RINS,(MI.ItS'I` BE C:OMPI.U111D)
<br /> 1. Record name and address(physiwl location) of the undergr€iund tank(s).
<br /> NOLh: Address MUST have a valid physical locaiion 'ricluding city, state, and iip code;.
<br /> P.O. *BOX NUMBFULS� ARE IYO`r.A.0 ,7I?.F�rABI1-,
<br /> Include nearest cross street and name of the c±perator.
<br /> 1 Phone number must have an area code. If the night nutnbe.r is the same, write "SAMI local€ion.
<br /> 3. Cheek the appropriate Cicax for TYI'l, 01" Il1TSLN:;SS OWNL`RSHIY (ex. CORPt)IZA°hI0N� I aDIVIl U'Al- etc s
<br /> 4. C`Itcck the appropriate b x for'T5I'h OF l'3I SI\'I'sSS.
<br /> S. If 3'acil4y/site is located within an Indian reservation or offie.r Indian truer lands, check the hox n ath=tui "YLS
<br /> 6. Indicate the NL;MBU',R of TANKS at this SHE',
<br /> T Record the. I.P.A, 11) # or write "NONE' in the space provided.
<br /> 11. PROPERTY OWNER INFORMA'1:ION &AI)I)12ENS (IMUS-1, BE C;OMPUT.171))
<br /> Complete all items in tris section, unless all items arc; the sante, as SFCTION -1; if the same. write. 'SAME AS SUE'
<br /> this section, Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> 111. "TANK OWNER INFORMN11ON & AI)I:)1tU S (14 u,'Tr lift C:OmI'I,1rrI:II))
<br /> Complete all items in this section; unless all items are the sime as `EC710N I.; If the same. write 'NAME AS SI`Ul" au•ross
<br /> this section. Be sure to check TANK OW1`€F sIFUI TYPE box.
<br /> Its. 130ARO 01 1 f)UA1.I7JV.1 ON USI 91X)RAGE FTE ACC:OIIP r Ix7[3MBER.(?ca U 1`BF C.'OMPI.F':119))
<br /> Tinter your Board of Equalization (BOF:) USF storage fee account number which is required before your permit applicaitkm
<br /> can be processed. Registration with the 110F,will ensure: that you will receive a quarterly storage fee return I :'Portin; the
<br /> $0.006,(6 mills) per gallon fee due on the number of gallons placed in your UST's. The BOE.will code Pers a ', l rwr
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the 1 ltf! w
<br /> questions regarding the fee or exemptions, please call the BOF at 91.6-323-9555 or write to the BOE' at the, _
<br /> Board of Equalization, E{.nvxonntental lTe,, Unit, P.O. Be>x 942379, Sacramento. CA 94279-€001.
<br /> V. PIss"F OI,IsUM UST Ir1NANCIIAL RESPONSII3IIXI-Y (MU,51` BPI WNIPLIaFED)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial €t pons• aty
<br /> requirements. UST's 6vmcd by any Federal or State agency are exempt from this requirement.
<br /> V1. 1,EGAI..NO`FUIC NI10N AND I3I1.L NG ADDRE S
<br /> Check ONE BOX for the address that wilt be used for B(YI1I LEGAL AND BIII.I1,G INOTjFgC:NnONS.
<br /> APPUC..AMF MI SF SIGN AND DNIM UIL FORM AS INI)IC:;,A'rlil).
<br /> IN x.I`RUCrION FOR 1111, LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the; State Board (916)719-2421, The.
<br /> facility number Wray be assigned by the local a cncy; however, this number must be rt€ rical and cannot contain any
<br /> alphai)etical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> I`I'I^s'1` 1F TtI'SF'C) 113I1 TI Y OF 7'111, LOCAL A(II:�IC"Y THAT ICISPE( 1'S THE I AC�IL I Y TO xllr.RlFaY'ITIS"
<br /> ACCURACY Y 01":(`III?INIK)RAINITON. UPS AI PLICATTON C ANISC)T BF I'Eft C E SSI1') IF 111F, I30I"AC(XHJPv p
<br /> N€;NWFI3 IN Ntl°l` FILLED IN. 11-111" URAL s""GFNC'Y 1S M SlONSWJ F° VOTZ !'Ilia r, CII 'IT1Fk
<br /> "s.C3CAL JS(.,-'!N,. `Ty;C City` Y" INFOR '1 CIN 30K AND FOIZ I :.)JtZWARDlN(; OST PORM "A" AND
<br /> A S.SOCIA'IT'D lataK'/, "'s)1`0 TIIE FOL tI)° 'INO ?a1.3I)I2USS.
<br /> SIWIT's OI' CALIFORNIA
<br /> AII:;R RESOURCES C ONI`FTOL WARD
<br /> C/o S. wlb F—PS.
<br /> 1)A.I,A "'ZOC:E S.SING C;T:NIER
<br /> 1'.ff 377
<br /> P . A 90723
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