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INSIRU(711ONS FOR COMPLETING 141)RM W GENERAL INSTRUCTION& 1. One FORM "A" shall be completed for all NVW PERAWS, PL'Rmrj'CIIANGE-S or any FACILI-ity/sriv INFORMAITON CILANGES. I SURMII'ONLY ONE(1) K)RM W for a Facility/Site, regardless of the number of tanks located ,it the �ile. 3. This form should be completed by either the Pk�W*Ifff APPI.ICAmr or the LOCAL AGENCY UNDURGROUND TANK INSPECTOR. 4� Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. 'T`OP OF BORAC 'MARK ONIjY ONE IIEM- Mark an (X) in the box next to the item that best describes the reason the form is being completed, FACIIXI-Y/SnV INFORMNIION & ADDRESS (mugr BE COMI'LLFIED) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT A(X-EFIABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code, If the night number is the same, w-rite "SAME" in proper localion, 3. Check the appropriate box forTYPE 01' BUSINESS OWNERSHIP (ex. CORPORA'11ON, INDIVIDUAL, eic.) 4. Check the appropriate box for TYPE OF BUSINESS, 5. If Facility/Site is located within an Indian reservation or olher Indian trust lands, check the box marked "W',S". 6. Indicate the NUMBER.of TANKS at this SITE. 7, Record the E.P.A. ID # or write "NONT" in the space provided. ff. PROPERTY OWNER MIORMA71[70N& ADDRF-SS (MUST BE COMPLUM)) 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 this section. Be sure to cbeck PROPEWFY OWNERSHIP TYPE box, III. TANK OWNER INFORMA17ION &ADDRM (MUST BE compiL-rm) Complete all items in this section, unless all items are the same as SECFION 1; If the same, write 'SAME AS Srn�r across this sectiom Be sure to check TANK OVINMI19UPTYPE box. IV. BOARD OF EQUA117WnON USF STORAGE F*EE ACCOUNT NUMBER(MIST BE COMPIHMD) Enter your Board of Equalization (BOF) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the %006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from 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 questions regarding the fee or exemptions, please call the BOE at 916-.323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-MOI, V. PEFROLEUM UST FINAW2M. ,RESPONSIBUX17Y (MUST- BE COMP�1,ff M0) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility' requirements. USTs owned by any Federal or State agency are exempt from this requirement. VL 11iGAL NU11WAITON AND BHJ-JNG ADDRFSS Check ONE BOX for the address that will be used for BOTTI I.EYAL AND Bn.JJNG N011111CATtONS. APPLICANT MUS717 SIGN AND DATE171111 PORM AS INDICATEI). INSIRUCIION FOR THE DOCAL AGENCIES The county and jiurisdiction numbers are predetermined and can be obtained by calling the State Board (916)7.39-2421. The facility number may be assigned by the local algcncy, however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the Siitr- Board to assign the facility number, please leave it blank. rl' JIS TTIF RE-SI"NSIBILITY OF T1IF 1,00'0,AGENCY IIIAI'INSPEC`VS THE FACHITY TO VFRIVY ilit' ACCURACY OFTIll' INFORIVIKHON, 'ITHS APPLICN[ION CANNOT BE PROCESSED IF TOP" 110C ACCOIJiN-I' NUMBER IS WTI' F111,11) IM '1711, LOCALAGUNCY IS RVSPONSIBII-� FORTIIE COMPLLqION' OV-111j; LOCAL AGENCY USE, ONLY' WFORMAT(ON J)OX AND FOR FO!�W# ONE FORM WAND ASSOCWrEb I?ORM W(s)TO THU, iT)k.l,0WJN*G;%PjjRESS' STAW OF CALIFORNIA S`rWD7 WAIFR RUNOURCES CONIROL BOARD C/O &W-F-11.P.S� DJVFA MOCTSSING CEWITR P.O� BOX 527 PARAMOUNT, CA 90723