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IN91'RIX711ONS MR CONIPLLITINO FORM 'A'
<br /> GE.NFRAI, TN',�WRUCIION&
<br /> L One 17ORM ""�' ,",all be completed for all NEW PURWIN, PI.,,RMrI'CIIAN(;I-S or �wv FACILITY/Sn'l;
<br /> of uink�" localod '11
<br /> 2� �-� iiVi i k�,NtE(1) FORM 'A" for a Facility/sitc, regardless of tile lilln10("'I
<br /> 3. Thi,, '� �� :,i ?uld be Completed by either the PERMIT APPI1CANI'or ilic LOCAL AGI`.NCY UNDFROROUND
<br /> TANK IN'�1'1'(TFORL
<br /> all requested information.
<br /> 4. Please typ�; clearly ,
<br /> 5, Use a hard ;-.��mu writing instrument, you are making 3 copics.
<br /> Of?FORME "MARK ONLY ONE ['11i'Mo
<br /> Mark an (X) in the box next io, the Item tbAt best dbscribes (he reason the forni is being conipleted.
<br /> 1. FACIIXFY/SfrF INFORMNITON & ADDRE&S (MUST BE COMPLE'IED)
<br /> 1. Record.narne and address (physical location) of the undergound tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX NUMBI.T.RS ARE NO(F ACC17FABLE.
<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 "SANIF" in proper location,
<br /> 3. Check the appropriate boy�or TYPE 014' BUSINESS OWNERSHIP (ex. C0RI1('WA'l1(_.)N, INDIVIDUI/ul' ctc�)
<br /> 4. deck thk vppropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YE.S',
<br /> 6. Indicate the NUMBER of'I'AINKS at this srrr,,.
<br /> i" in the .
<br /> T. Record the E.P.A. 11) # or write "NONE space provided.
<br /> II PROPERTY OWNER WFORMS110N&ADD'Rt-.,S' (MbST BE COMPLU11m)
<br /> Complete all items in this section, unless all items are the same as Sl-..�.CMON 1;'if�thc sanne,wwrite *SAME AS SITE c r c�.S-s'
<br /> this section. Be sure to check PROPERIN OWNERSIITP TYPE box.
<br /> M. TANK OWNI.,.R INFORMAITON & ADDRESS (MUST BE COMPIJ-�,]`ED)
<br /> Contplete all items in this section, unless all items are the same as SF(710N 1; If the same, writd SAME,AS SITE
<br /> this section. Be sure to check TANK OWNE IZSI1U1 TYPE box.
<br /> IV. 130ARD OF BQUAIJMnON USI'SrORACYE FEE.ACCOUNT NUMBER(MUST BE COMPUT.9.1))
<br /> Enter your Board of Equaliiation (BOE') U91' stor-age fee account number which is required before )N)ur pern!%�t'applicatiotr
<br /> can be processed, Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0.000 (6 mills) per gallon fee due on the number of gallons placed in your I"IsTs. The BOE wiH code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number-,vilh the BOE or if you h�,ive ativ
<br /> questions regarding the fee or exemptions, please call ihe BOE at 916-323-9555 or write to tl*B(A�,, at,the f(�lowin,� address:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 9,1279-0001,
<br /> V. Pl-zMOI.,UUMUSTI�INANCIAI. Rl-�-SPOMH3Hn-i, (mu,,;-rBFcompi-jziTi))
<br /> Identify_tWe inethdd(s) usedby the cwt1dr and/or operator in meeting the Federal and State financial responsibility,-,
<br /> requirements. USIs owned by any Federal or State agency are exempt from this requirement,
<br /> VI LEGAL NO'11FICATION AND BILLING ADDREM
<br /> Check ONE BOX for the address that will be used for BO`I'H LEGAL AND BUJING N(y][IFICA711ONS.
<br /> APPLICANT MUST SIGN AND DA71'F'11111, FORM AS INDICNI1113.
<br /> INSrRU(TITON FOR'I1IL1 LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. Tim
<br /> facility number may be assigned by the local agency; however, this number mus-t be numerical and cannot contain any
<br /> alphabetical. If/he local agency prefers the State Board to assign the facility number, please leave it blank,,
<br /> 7
<br /> rr IS uIE RESPONSAIIIIII'Y OF 11W LOCAL AGENCY INSPI Tf 11 FACIIXFY TO VERIFY '11114,
<br /> S
<br /> ACCURACY OF D I E' INI�O RMA'110N. 17JIS APPLICNHON CAN r-, 14 T"SED IF'I III, 110ti' A CC )UN'T'
<br /> NUMBER IS NOT FILLED IM 'ITIF LOCAI.,A(;ENCY IS RV'Sf'(�'N",1111' FOH '1111' COM111,F11ON OF'111F
<br /> *LOCAL AGFNC Y USE.ONLY* INFORMATION BOX AND I f Oill WARDIrqC ON'T" FORM "A" AND
<br /> ASSOCIATED FORM W(s)'11) 111E FOLLOWING ADP Pt
<br /> S'I'A7111 OF CALIFORNIA.
<br /> WNIER RESOURCES CYWYK(W 10 PARO,
<br /> C/0
<br /> DA7.J'.A PROCESSING CEN`11TR
<br /> P.O, BOX 527
<br /> PARAMOUN17, CA 90723
<br />
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