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INSIRUC33ONSFOR OOMPLJ.,,'rJNG FORM w
<br /> (311"QM!""ItAtf,
<br /> - Onc FORM "A" shadl be ccmnpf,,�cd forall NEW TIERMUS, PERMU(MANGES or any FA("'H,rrY/srl'1;
<br /> INFORMY]ION (,,,IIANGF,!,;,
<br /> 2, SURIVIrl'ONLY Olall�(1) -A' for a Va6fity/Silc� regardless of the number of lanks lo"""Icd �i! di�"
<br /> " "'Mi
<br /> L s l'o-M "hould 10 ith r ti- PTr or the LOCAL AGENCY UNDURGIMUND
<br /> 'C conlpk�tcd bly 6 is �e I APP11CA.
<br /> 'FANK INSPECPM
<br /> eL PIc"asc ?viw (if pr�pt deariv naqu,,ested infomnation,
<br /> 5, a hard pc"nwt �,vridng inwalnf�ni, you are inaking 31 copies,
<br /> "'Op ()I'1'B"'MIS1 ONLY ONE
<br /> Mark an (Xi in the Nox, nexi t"'l the it""-'nl that best (kscritcs tile reason the forin is being coniptc�cd�
<br /> 1, FACHMI/SOT,INMRM/V),ICJN & ADDRV',,;S (MIJI;l" BE OC)TAPIM1111)
<br /> 1- )Iecord name and address (physical location) of the ritiderground hink(s')�
<br /> N()']T'�: Address MUST hive, a valid physicai location, including city� state� and zip code,
<br /> P.O. BOXhITYMBEW;ARE NO`1'ACCliFFAMIL
<br /> Include nearest cl',,iss stroet and name of the, operator,
<br /> I io- unib 'st, ha in area code, If the n�gftt n-umber sme, ix- I/vNI -�cr ks-aiion-
<br /> 'l as It 'cr MG ve I is the S" "ne ",'S 'E' in Prol
<br /> Ch�x�k the appni-priare box for TYPE 01" BUSIN41'sS OWNERSHIP (ex. CORPORA'110N, INIAVIDUAL,
<br /> Chc,,ck the a roftti�'ne box for TYPE OF BUSINU"S&
<br /> RP ,
<br /> 5� If is located within an Indian rcservation or other Indian 1rust lands� check the box markeo "YES',
<br /> 6, fildba�e the NUMBER of'f',,'�NKS at this
<br /> "te 'NONT," in flic space procrided�
<br /> Rc�,ord the ETA, 11) # or
<br /> IL PROPEKIT OWNER TKIAORMA'DUN A ADDRYSIS (MUS-V BI"COMPLE4,1714,D)
<br /> Complete, all items in this section, rudess all items are the same as SUCUON 1; if the same, write *S'AMill AS Sl'IT' acro,,,s
<br /> this section, Be sure to check PROPEKFY OWNERSHIP TYPE box,
<br /> III, 'Ps'NK OWNER INFORMA370N &ADDREIRS (-ALTFI' 13E Cd.)MP1,u-'1TT))
<br /> all itcnis in thif section, urfless ail ircnis ore !he sanic as SECTION 1; If tire eame, ilrite '&'lMU"AS SUH,
<br /> ";"Cction, fie sun,�, check TAalK OVINAU-JR.S111VIYPE,box�
<br /> I'V', JR)ART) OF T`,)QUA11ZA'I'1()N UST-Fk %'J`O'PAGV Irf"531 ACCOUNT NUMMiR(MUSM RE,CX)MP1JrITqM)
<br /> Enter , ur Board of Lkisalization U6F storage fee account number which is requirtel bidbre your pertnit application
<br /> can be processed, Rcgimrafion vvilh the B01,,,,esH ensure that you will receive a quarterly storage fee return in rqv)rtimy the
<br /> S0,006 (6 mills) per gallon ice due oil the number of Sedans Ill,aced in your US`rs. 17he BOE will code persons cecm"m
<br /> tmying t
<br /> stora , fee so returns will not be sent, If yort do not have an rwcount number with the BOU or if vou ha'VC ai)v
<br /> ge
<br /> questions regarding the fec or exemptions, please call the BOE at 916-323-950 or write to the 110F' at the follov,,im, addnes's'
<br /> Board of Fkl ualization, Envirom-riental Fec a 11 Unit, P,O, Box 9,12879, Sacramento, CA 94279-000L
<br /> V� P17,11MIX11,11-N11 UST MMANCIAL RHSP0N,1,-,IBILr1-Y BE C0mPjjTJ1F1))
<br /> Tden�ih� the, rrvcthod(s) u-sed bw Ilic owner and/or operator in meeting the Fedorst and State financial responsibifily
<br /> "Fr, olvned by any I"ederal or State agency are exernpt: folm this requir=em,
<br /> US
<br /> VL 11-,X-Ml, N(OMCKnOld AND ]BIJJJUW;AD,DRESS
<br /> Check ONI", BOX for the address that -,vill be used for B(YrH LEGAL AND MUING WY17MCA'TION1
<br /> ,A]"FLICANT MUST'SKIN AND MUM'17111 MRMI AS UNDICATUD,
<br /> INSTRUCUION FOR THE,LOCAL AGENCIPS
<br /> Thc cou-my end joriediction numbers are predetennined and can be obtained by calfing the State Board (916)'739-2421, The
<br /> rumber may be assigned by the local agency-
<br /> however, this number must he numerical and cannot coatan. ativ
<br /> mphalicticad, Ifffic, lcical a
<br /> gency prefete tbe State B000l, to assign the facility number, ph�aee leave it blank�
<br /> 11'I'S"' flill RE'SP(MM'SIBUXIFY OF 111,11( AGENCY THAT INSPECIIS''111,13 FACUTY TO V1;RT1sY'DIF,
<br /> OF 11,11E le'UPCIRTMA-110N, THIS APP11CAtTION CANNOT RE,, PROCESSUD ]FIME,F1011 AC' )UNN'
<br /> 11JUIM!", flf, IS N(Yl' FILT FT� IN, 'I'HE LOC'1/14L"MY-fFUNCY IS RUSPOINSMIls FOR T1111 COMPIMION Ol, '11111
<br /> A(,i1'1,",',NC',`V` USL ONLY' INFORMATION 1)(IM AN13 FOR 11RORWARDING ON[i FORM 'A' AND
<br /> AS;S('K-" Id)JZM `11`(� TO -1111,V()11X)sF;,Nl1 ADDR14','S's,
<br /> 0 ltbl A
<br /> F`
<br /> ST A COMI 0 rj(
<br /> WIT- VV -' M -R L )ARD
<br /> DANTA, PR fCJ,-P'.WMN(x
<br /> P'O. TIOX 52-1-1,
<br /> P/MAMOIJNFJ� CA 90723
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