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INSIRU(711ONS FOR COMPLETING 141)RM W <br /> GENERAL INSTRUCTION& <br /> 1. One FORM "A" shall be completed for all NVW PERAWS, PL'Rmrj'CIIANGE-S or any FACILI-ity/sriv <br /> INFORMAITON CILANGES. <br /> I SURMII'ONLY ONE(1) K)RM W for a Facility/Site, regardless of the number of tanks located ,it the �ile. <br /> 3. This form should be completed by either the Pk�W*Ifff APPI.ICAmr or the LOCAL AGENCY UNDURGROUND <br /> TANK INSPECTOR. <br /> 4� Please type or print clearly all requested information. <br /> 5. Use a hard point writing instrument, you are making 3 copies. <br /> 'T`OP OF BORAC 'MARK ONIjY ONE IIEM- <br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed, <br /> FACIIXI-Y/SnV INFORMNIION & ADDRESS (mugr BE COMI'LLFIED) <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 A(X-EFIABLE. <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, w-rite "SAME" in proper localion, <br /> 3. Check the appropriate box forTYPE 01' BUSINESS OWNERSHIP (ex. CORPORA'11ON, INDIVIDUAL, eic.) <br /> 4. Check the appropriate box for TYPE OF BUSINESS, <br /> 5. If Facility/Site is located within an Indian reservation or olher Indian trust lands, check the box marked "W',S". <br /> 6. Indicate the NUMBER.of TANKS at this SITE. <br /> 7, Record the E.P.A. ID # or write "NONT" in the space provided. <br /> ff. PROPERTY OWNER MIORMA71[70N& ADDRF-SS (MUST BE COMPLUM)) <br /> Complete all items in this section, unless all items are, the same as SFCI'ION 1; if the same, write "SAMV AS Srf`E* across <br /> this section. Be sure to cbeck PROPEWFY OWNERSHIP TYPE box, <br /> III. TANK OWNER INFORMA17ION &ADDRM (MUST BE compiL-rm) <br /> Complete all items in this section, unless all items are the same as SECFION 1; If the same, write 'SAME AS Srn�r across <br /> this sectiom Be sure to check TANK OVINMI19UPTYPE box. <br /> IV. BOARD OF EQUA117WnON USF STORAGE F*EE ACCOUNT NUMBER(MIST BE COMPIHMD) <br /> Enter your Board of Equalization (BOF) 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 USTs. The BOE will code persons exempt from <br /> paying the storage fee so returns will not he sent, If you do not have an. account number with the BOE or if you have any <br /> questions regarding the fee or exemptions, please call the BOE at 916-.323-9555 or write to the BOE at the following address: <br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-MOI, <br /> V. PEFROLEUM UST FINAW2M. ,RESPONSIBUX17Y (MUST- BE COMP�1,ff M0) <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 /> VL 11iGAL NU11WAITON AND BHJ-JNG ADDRFSS <br /> Check ONE BOX for the address that will be used for BOTTI I.EYAL AND Bn.JJNG N011111CATtONS. <br /> APPLICANT MUS717 SIGN AND DATE171111 PORM AS INDICATEI). <br /> INSIRUCIION FOR THE DOCAL AGENCIES <br /> The county and jiurisdiction numbers are predetermined and can be obtained by calling the State Board (916)7.39-2421. The <br /> facility number may be assigned by the local algcncy, however, this number must be numerical and cannot contain any <br /> alphabetical. If the local agency prefers the Siitr- Board to assign the facility number, please leave it blank. <br /> rl' JIS TTIF RE-SI"NSIBILITY OF T1IF 1,00'0,AGENCY IIIAI'INSPEC`VS THE FACHITY TO VFRIVY ilit' <br /> ACCURACY OFTIll' INFORIVIKHON, 'ITHS APPLICN[ION CANNOT BE PROCESSED IF TOP" 110C ACCOIJiN-I' <br /> NUMBER IS WTI' F111,11) IM '1711, LOCALAGUNCY IS RVSPONSIBII-� FORTIIE COMPLLqION' OV-111j; <br /> LOCAL AGENCY USE, ONLY' WFORMAT(ON J)OX AND FOR FO!�W# ONE FORM WAND <br /> ASSOCWrEb I?ORM W(s)TO THU, iT)k.l,0WJN*G;%PjjRESS' <br /> STAW OF CALIFORNIA <br /> S`rWD7 WAIFR RUNOURCES CONIROL BOARD <br /> C/O &W-F-11.P.S� <br /> DJVFA MOCTSSING CEWITR <br /> P.O� BOX 527 <br /> PARAMOUNT, CA 90723 <br />