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<br /> UC 11ONS IVR C OMPI.EsiING FORM " "
<br /> GENERAL S'i`lt[3 . C)NS:
<br /> L. One EaCtRM "A" shall be completed lc: C:I is os•any hAC1lXl'°l/SrrF
<br /> INFO 'HON CHANGES,
<br /> 2 S B it C N[ ONE(1) rum "x ,or s l icifity/Sna, rc,a a of the number of tanks located at 0z sitc.
<br /> 3. This form should be completed by eats er t `rc PE IT SPI UC-",'..4Tor the L CAL A("aI N(Y UNDERGROUND
<br /> TANK INSP &M, )k
<br /> 4. Please type or,print clearly all request,'A =.tc rranation.
<br /> 5. Use a hard point writing; instrument, au ;. snaking 3 copi .
<br /> TOP OF FORM.'MARK ONLY ONE nmm-
<br /> $ark an O in the: box next to the item t.tat describes the res 3,a the form is being completed.
<br /> I, FACILTIT/SM3 WORMA110N&d DDRE r ( ' 'Jill" BE CO I�1
<br /> 1. Record name and address (physical of the under r,wr>a' 'aank(s).
<br /> NOTE: Address MUST have a valid hi ical location tnclauii<,xf. a:ay, state, and zip aide.
<br /> P.O. BOX NUMBERS ARE .t. :' C C* I3I2
<br /> Include nearest cross street arka,Y ....:zte of the operator.
<br /> 2. Phone number must have ars area code. If the night number is the Sastre, write "SAME"' in proper location.
<br /> 3. Check the appropriate bloc for TYPE OF BUSINESS OWNERSHIP SHIP (ex. CORPORATION, INDIVIDUAL, etc;)
<br /> 4. Check the appropriate box for TYPE OF BUSINEf5S.
<br /> 5. If h"aeility/Site is located within an Indian reservation or Cather Indian trust lands, check the box marked "Y11"S",
<br /> & Indicate the NUMBER of TANKS at this SITE,
<br /> 7. Record the E.P.A. ID # or write "NONE" in the space Tirovided.
<br /> it. IaIkOPL4 TY OWNER T C) ADDRESS Si"BE:COMPI MM)
<br /> Complete all items its this section, unless all items are the same as SECTION 1; if the same, write *S l3 AS Srll!'! across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> M. TANK OWNER IN12ORMKIION &ADDRESS ( UM'BEt °E
<br /> Complete all items in this section, unless all items are the same as SECTION 11 If the same, write "SAME AS 1,91*11" across
<br /> this section. Be sure to check TANK OVVNERS1111PTYPE box.
<br /> IV. BOARD OF Ix tI -11ON UST S-1)(I)RAGE I ,ACCOUNT NUMBER (MUST HE Z11 )
<br /> Enter your Board of Equalization (BOE) CJ91` storage fee account number which is requited before your permit applic<alion
<br /> can be processed. Registration with the BOE will ensure that you will receive as quarterly storage fee return in reporting the
<br /> MOM (C trills) per gallon fee due on the number of gallons placed in your UST's. The EICIIW will code persons exempt front
<br /> paying the storage fee so returns will not be 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; addressi
<br /> Board of Equalization, Environmental Fees Unit, P.O..Box 942879, Sacramento_,CA 94279 0001,
<br /> V. PETROLEUM]LIST HNANCA.M. IB11X rl BE C:t>' I )
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. t1STs owned by any Federal or State agency are exempt from this requirement.
<br /> VL LEGAL N(YM4CA'110N AND B111ING ADDRESS
<br /> C beck ONE BOX for the address that will be used for Et0111 11MAL AND B111ING NCY1114C' '111
<br /> PI ICANr MU91 STEN AND AIT:?°TIIEt FORM AS INDICATED.
<br /> LI m CJN'FOR THE LOCAL AGENCEM
<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 trust 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 /> rf IS`IT I Oil 11111 LOCAL AGENCY THAT S I Ir 110,VERWY 1171E
<br /> ACCURACYOV ITIEg INFORMATION. 311 S APHICATION CANNOT BE PROCESSED r"1 r Bolt AccouNr
<br /> NUMBER ISN I IC.I, E) I3 , C) aA IS NSILLIt SIT P COMPILqION OF°CEt'
<br /> "I OUiL.AGENCY USE C)N1,Y' E1 TION BOX AND FOR ONE PORM " "AND
<br /> ASSOLIM17D VORM "B"(s�`li`C) TTIB POUOWING AbD .
<br /> Si Tt OF C`.
<br /> C/o S.W."-p-&
<br /> DATA lP OC. S. Ca C IC?IC
<br /> P.OBOX 527
<br /> PARAMOUNr, CA 9(fM
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