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<br /> 1ySSfR IC1"It:NS FOR C"OMPLIM. GI FOR "A* t
<br /> GENERAL INNSIRUCDONS
<br /> 1. One FORM "A" sbali be completed for all NEW I"111MHS, PER IT 01ANGEi or ally FAC IL I`Y Sri`F
<br /> INFORMArION C1111IaTGES,
<br /> 2. SUBMFI°ONLY ONE(1) 17ORM 'A for a Fachity/Sitc, regardless of the number of maks loc 'cd a,
<br /> 3, This form should be completed by either the PEV0,11'r APPLICAmr or the LOCAL AGENCY C7ND11,01Z )I-ND
<br /> TANK INSPECFOR
<br /> l'Ic ase ty or print clearly all requested info.matson.
<br /> Use a hard point writing in triatrent, you are making 3 copies.
<br /> TOP OFFO%M. IMARK ONLY ONE I'I"I?
<br /> Mark art (X) in the box next to the item that bestdescribesthe reason the form is beim, 0)n,,pletcd,
<br /> 1, AC 11,11-YIS III F .1 C3 I7 E .s(MUST BE CO . I,I 110).
<br /> 1. Record mint: and address (physical location) of the: underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and rip code,.
<br /> P.O. I= NUMBERS ARE N(Yf ACCITYA1311t
<br /> Include neatest cross street and name of the operator.
<br /> , Phone number must have an area code. If the night number is Gic sante, w-the `Sgf� 11,1` in proper kx,tilion,
<br /> 3. ;heck the appropriate box for`€ PE OF' BUSINESS OWNERSHIP (as, CORPORATION. INI,N '"sl)t-AI,. .::tcr.#
<br /> 4, Check the appropriate box for TYPE OF Iia SlNr,.S.
<br /> 5, If Facility/Site is located ;villain an Indian reservation or other Indian trust lands, check the: box marked YES
<br /> & Indicate the NUMBER of`I"AN S at this SITE,
<br /> 7, Record the E,P, , ID # or write "NONE" in the space provided.
<br /> 1. PROPTUVIT OWNER C `11CI IIIC ss( us`r BE CoMPLErng))
<br /> Complete all items in this section, unless all items are the same as SI C:"ZION i, if the same, rite 'Std st-ru,
<br /> this section. Be snare to cheek 'IZC7PER`FY t14ti%:NERSHIP TYPES box.
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<br /> .TANK OWNER N :ORMA 3°10 II. S(fi t`,1`11 pS)MPLt TD)
<br /> Complete all items in this section, ;amess all items are the same as SFC I°I() l; IS' ",rc, same, write '.'SAME AS STIT alr«;s
<br /> this section, Be stare to check TANK OWNEULS111PTYPE box,
<br /> I1', BOARD OFI ATIZ ITON U51"SMRAGE FEE C(-'(.)UNr NUMBER ( Itas1" 1I.a, S Irl.vI1;,D)
<br /> Enter year Board of Equalization ( 30E) UST storage fee account number which is required before your prr nrit a;t;ti.ation,
<br /> can be processed. Registration with the BOE will ensure that you will receive as quarterly storage fee retw-t is'" reporting the
<br /> $0,006 (Gi mills) per gallon fee due on the number of gallons placed in your USIs. The 'BC1F', will codes per,,oms ex,.—tpa from
<br /> paying the storage fee so returns will not be sent, If you do not have an account Purnber t ills the IAGII tat' "t y ou hI ', any
<br /> questions regardingthe fee or exemptions, please call the BOF?at 916-321-9555 or write to the BOF at the. follo,ai", a,,ddlcssi
<br /> Board of Equalization, Environmental Fees Unit, P.OBox 9I2879, Sacramento, CA 94279-0001,
<br /> a PEIIZ0LTiUM t1 1`FINANCIAL N 1 (Mt3 H COMP,11-o)
<br /> Identify the method(s).used by the owner and/or operator in meeting the Federal a:°bei State financial responsibility
<br /> reelnirenrents. USTs owned by any Federal or State agency are exempt from this realuirernem,
<br /> Check ONE BOX for the address that .vill be used for I3C9`nI I1 1,AND BILLING NOTI[FI' II 1 S,
<br /> APPLICANT US SIGN AND 1IATF ITIE FORM AS INDICA117D.
<br /> INS';I'ICI3(:IC1l FOR TTIE 1A)CAL AGENCTFS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling; the State Board (916)739-2421, I'h
<br /> facility number may be assigned by the: local agency; ho t-er, this number rnust be numerical and cannot contain any
<br /> alphabetical. If the local agency prefere the state Board to assign the facility number, please leave it blank.
<br /> I'IS-I.II17 RESPOINISIBILIfIT OF 17111 LOCAL-AGINCY TTIA 'INSPEC771s'111H 1~ C&IErrY TO VERWY 1111
<br /> z1CCIl" , OF 11H-;INFORMN170N. `°IIIS ItI P11C.N110N C I`BE 1 ROCI� l-,,D IF`1IIE 1301,71 t:t CtiCat.NT
<br /> NUMBER IS N(YI` FILLED Its. ITIE LOCAL r.: w IS -SPONSIBLE,FOR IIIE COMPLETION Oil`111H
<br /> 'LOCAL AGENCY USF ONLY' INMRMN.IION BOX AND FOR FORWARDING ONE FORM 'A' AND
<br /> .SSOCI FFI) FORM "13'(s)TO 171I?FOLLOWING ADDRF.ss,
<br /> SYN11.1 OF C;,IELHIO N1
<br /> I" I" I WAIMR, RESOURCES OURCE NI` 1L BOARD
<br /> ' C°/G1 FGA .
<br /> NEA PROC"INS NG CENIER
<br /> RO. BOX.127
<br /> PARAMOUNF, CA 90723
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