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IN,K UCITONS FOR.C'O PI.ETI: .k FC) 'A"
<br /> m
<br /> ai sl 1:10,1, T �
<br /> , ,W i )RM °:a" shad be completed for all NEW PERMITS, PERMIT K'11ANGES or any FAC(F,I'IN/Srili
<br /> .NF(,)l 1-1ON t"lillNGE—S.
<br /> 2. S-UB rl-ONLY ONE(1) FORM 'A7 for a Facility/Site, regardless of the number of tanks located at tlu, silo,
<br /> :3. This fotasa should be completed by either the PERMIT APPIIC `on- the LOCAL AGENCY UNDI) RGRO)IJNl)
<br /> TANK INSPI.?C`FOPL
<br /> Pl3,z,,, ? e ,�_ print clearly all :requested information.
<br /> a hs point writing instrument,you are snaking 3 copies,
<br /> T,011 _ ,.V "MARK ONLY ONE FIT:'
<br /> Nl,rk as (X) in the box next to the item that best describes the reason the form is being conapleicd§
<br /> UST BE COMPI, D)
<br /> 1. Record mane and address (physical location) of the underground tank(s).
<br /> `vO T`FI: Address MUSF have a valid physical locations including city, state, and zip'code.
<br /> F'-(). BOX NUMBFIUS ARE NC E`Accfluvmmi
<br /> Include nearest cross street and name of the operators°,
<br /> 2 Phone,number must have an area code. If the night number is the same, write "SAMP' in proper loci i u.
<br /> 1e,heck the appropriate bex for TYP > OF BUSINESS OWNERSHIP (ex. C'C)IZI't'3I211"HON, IN )IVIDUAI.,, etc,)
<br /> 4. Check the appropriate box for TYPE 014' BUSINESS.
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box anarked Ylas".
<br /> 6, Indicate the NUMBER of TANKS at this SI'PF'-
<br /> 7. Record the ,P 4, ID # or write "Nk.)SIF;" in the space provid'd„
<br /> IL PROPERTY OWNER 1Mz0RMX110N& ADDRF—SS ( uIR- BE (`,C) ISI p1m)
<br /> Complete all items in this section, unless all items are the same as SEC`I'ION L if the same, Write 'SAMF AS`;£17?, acm,,s
<br /> this section. Be sure to check PROPERTY OWNE SHIP "3 YPE', box.
<br /> III, TANK OWNER LNFORMNHON & ADDRFSS, (MUM-BE co PLI?7m)
<br /> Complete all items in this section, unless all items are take same as SECTION 1, If the same, write 'SAME,AS SI'I'I a�rt?ss
<br /> this section, Be sate to check'1'A IC C) SLAP TYPE box,
<br /> IV, BOARD OF F=.0 IJAL17 "10 U S'S'IT)RAGR FEE ACCOUNrr N TmBF? .S`F°BE comp .Ia'11a13)
<br /> Enter your Board of Equalization (BOE) UST storage fee account number which is required befcare y<aur pe�rsa.it applicafinn
<br /> can be processed. Registration with the BC)F will ensure that you will receive a quarterly storage fcc return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's. The BOE will code.persons exempt from
<br /> paying the storage fee so returns will not be sen`t. If you do not have an account numbcr'wiih the IIC)E;'`br if you havc 'ant
<br /> questions regarding the fee or exemptions, please call theBOE at 916-323-9555 or write,to-,thc1,13O at',theFfollowing �ddres;;:
<br /> Board of Equalization, Environmental pees Unit, P.O942879, Sacramento, CSA 94'L70-0011
<br /> V. PUI"T8.C3I,EUM UST FINANCIAL RESPONSIBILM (MUSr BE C OMPLEs171? )
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and Slate financial responsibility
<br /> requirements. US"I's owned by any Federal or State agency are exempt from this requirement.
<br /> YI_ I.EGAI.N0TIFJ[CAnON AND B111 CI ADDRE&S
<br /> Check ONE BOX for the address that will be used for B07111 LIXI L.AND 1311,1..1 CI CATION%.
<br /> APPIIC a4 'MUST SICK AND RKI'?111E FORM AS INDIC A1'I D.
<br /> INSTRUC.711ON FOR'n-111 LOCAL AGPN(,WS
<br /> T'he 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 /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> I'1"IS°ITHT, R05PONSIBUXlY OF 7.1IEI LOCAL AL A GI:24(Y 7ITI,A'1' I: SPIXIS'1'IIII FAC;IIX1'Y'J`O YIMIFY°11111
<br /> ACCURACY OF'['III:! INFORIAKFION. 77115 APPUC'ATION C%,sal`NO`17 BE PROC ESSE:?I) 11:11111 1X)E AC,C;C)UNI'
<br /> NUMBER F?IC ES NOT Is1I,i.I?I9 IN. 111E LO(W, Cir C IS k PONSIBLE I °11 .,C:C)MPL CllgrC)F7 1 . .
<br /> "LOCAL AGENCY USE, C)NL Y-'I `Fk) t1 i10 AND FOR FORWARDING ONE PO '"A'AND
<br /> ASSOC:IJV17ED FO "B"(s)TO 'IIIE; F LIA) INN ADDRESS.
<br /> SIAII?WATER Rig' UIIC F S C ONIR L BOARD
<br /> DATA PROCESSING G C"I;NIT,,R
<br /> P.C). BOX 527
<br /> PARAMOUNf, CA 90723
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