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<br /> IN'STRUC11ONS FOR COMPLFrING 17ORM W
<br /> GENERAL ENS TRUCHONS-
<br /> 1. One 17ORM "A" shall be completed for all NE PERMYIN, PERMrI* (31ANGE-S or any FACII.rry/sriv.
<br /> INFORMA11ON CHANGES.
<br /> 2. SU`BMrf`ONLY ONE (1) FORM 'A' for a Facility/Sitc, regardless of the number of tanks located at the s0c,
<br /> 1 This form should be completed by either the PFRWYAPPLICANT or the LOCAL AGEINCTY UNDFW;ROLIND
<br /> TANK INSPIX7170R.
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument, you are making 3 copies.
<br /> TOP OF FORW- "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 /> L 1 ACJLr1T/,SrIT. INFORMA110N &.ADDRYI&S (MUSE' BE COMPLin TID)
<br /> 1. Record name and address (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 NOT AC(T.-TrAIIII-L
<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 "SAN1,11,." in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORAJJON, INDIVIDLIAL, etc,)
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box rna4cd `)Tls".
<br /> 6. Indicate the NUMBER of TANKS at this SfIE.
<br /> 7, Record the E.P.A. ID # or write "NONE" in the space provided.
<br /> EI. PROPERTY OWNER IM70RMNnON& A13DRF-SS (MIJ.I;r BE COMPLETED)
<br /> Complete all items in this section, unless all items are the same as SFCPION if the same, write 'SAME';AS 5111;
<br /> this section. Ile sure to check- PROPEIM OWN[T-SHIP TYPE box.
<br /> Ill. TANK OV".'R. INFORMA-TION & ADDRE&S (MUST'BE CO.MPIHIT3))
<br /> Complete all items in this section, unless all items are the same as SECTION 1: If the same, write "SAME AS SITI--
<br /> this section. Be sure to check TANK OWINIM. S1111"INPE box.
<br /> IV. BOARD OF EQUALYIAITON usr SrORAGE FEE ACCOUNT NUMBER (MIJ51' BE (X)MP1Yj1;D)
<br /> Enter your Board of Equalization (BOE) US-P storage fee account number which is required before your permit appliusition
<br /> call be processed. Registration with The BOE will ensure that you will receive a quarterly storage fee return in roporling the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USI's. The"BOU will code persons
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BOF or it' you havu any,_
<br /> questions regarding the fee or exemptions, please call the BOF at 916-323-9555 or write to the BOF at the following address:
<br /> Board of Equalization, Environmental Fees Unit, P.O, Box 942979, Sacramento, Cik 94279-()()()1.
<br /> V. PL,7rROLFUM USTFINANCIAL REsPoNswuny(Awsr BE,complx-j.-ED)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. UST's owned by any Pederal (n,State agency are exempt from this requirement.
<br /> VI, LEGAL N(YP111ICXrJ0N AND BIIJJNG ADDIWSS J
<br /> Check ONE, 13OX for the address that will be used for BC7I11 LEGAL AND BUJING N(TIJIII(WtIONS.
<br /> APPIJ(ANT MUST SIGN AND DNITK'nIE IURM AS YNDI(:NIIA-).
<br /> IN .I'R1JC`I1ON` FOR'111E LOCAL AGENCIEN
<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 /> alpliabelicaL If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> 171'IS'ITIE, WiSTONSIBUX17Y OF'11W LOCAL A(;I.,,N(,Y 'DINT' INSPECTS 111E FACIL17PY TO Vl-,-RIFY'1111;
<br /> A(X-URA('Y 017'1111 INFORMA110N. ITTIS APPH(WnON (ANNO`1' BF PROC[:!-SSE.D IF 174E DOE ACCOUNI,
<br /> NLJMBFR IS NOT FILLED INe THE LOCAL AGINCY IS RESPONSIBLE FOR'nil! CONIPLFTION 017 111E
<br /> 'LOCAL AGENCY USE ONLY' INFORMN11ON BOX AND FOR M- RWARDING ONE IX)RM 'A" AND
<br /> ASSOCIA717ED FORM 'B'(s) -170 ITIE, R)LLOWING ADDRESS.
<br /> S,rA'IE OF CA11FORNIA
<br /> NFA17
<br /> i WNITR RESOURCf-S lCONIROT, BOARD
<br /> DNI'A PROCESSING CTVITiR
<br /> P,O, BOX 527
<br /> PARAMOUNT, CA 90723
<br />
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