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l,�f f,A'shats � :° i2t,nlcfc ct t, 1 "_ ,. �`' aSf rr <�; �,
<br /> INFORIANITON CHANGES,
<br /> = R /St .SI �ONLY sie _ c,a the ,.'
<br /> 3, 'Drax 11"orm should be completed by ettt. E clic. l'f'R?AII'3 AAI""t fC M`MV he I,`"C Al,A(si,NU C ,.,
<br /> 'TANK Ill-SPECIte a
<br /> I tca-,; iypc or print clearly all request, in'-,"nrc, fioxn.
<br /> JsW a hard point w,tttrtg tnst'rur it., , rnaking s
<br /> a n.t. to FORIN - , 2MRIC" ONIA ONE
<br /> d ( in the <.c..t to ?iac ftcol a t'._t st describc,, n,,. e., , t €' €an ,, '.�.
<br /> Reco,"d name and addre.)s (Physical of the a n>tcng,<'. Eakls),
<br /> Address MUS" have a validh',,,�, s. ' cakion r'• st a E. and tC codc;-
<br /> ROt, BOX ?'UrMIO"$ S,ARF c. .. .,
<br /> Include nearest cvcau, street aq-T of the crC1r,,,,iijr
<br /> �.. Phome n:ndeer treat have an area colla., titg;'t i".ingtr: is .t.., "sa 2.. -icy SAg'P in p}'o, t€„a`io,?,
<br /> .,
<br /> 3. ��kas��°k die appropriate ltrx%°€;r a"''��, Of," ��"`SI."�En:f; t.o ?�t��k�:�111k (e,.,
<br /> 4Check the appropriate box for n,-PE t3I' IWISINIfSS,
<br /> *- If Fatuity/Site is located witfnn art Indian reservation, or other aincf nn ,act_t lands, c1 ck €£it ,;sx E i.t cU "Yl 'S'
<br /> x; frn ieate the NU IBEll, o<""1.`AKS at this S,1`1";'
<br /> �
<br /> " Record the 2>.I A. ID .Ix or writs 'NONE, in, the space fnrovdcl.
<br /> II. VR(1)I I;1C.I OWNER? INIAWRMAMON& ADDRFiSS (M1,51' BE Comf`1.1111,11))
<br /> "1.111))
<br /> Y ompiete .,cal Yterne..nY this 'lection unless all fte SES ao, the sate, was SE"'PON x,.N s"; if .,c AS'
<br /> ,his scctkjn, Be wire to chcc.:. k' C3Pf:1C.'I`Y OWN1,111611111 1`CP f tic:..
<br /> I.ff. '1:eAt"fIs OMWI C I kf ORM A'1"1CI MIMESIS a 11x51'111:l C O I'LI 1'f0)
<br /> (,t,S,.7`pl'ete kali flit;t7."is in this section, vitless all heals are the sa nic as S€,f;f:"(-) 1: it the €'c, �_., f�..; AS,"-,T I:"f3
<br /> this section, .I'lle sure to check '1ANK C1 . 1 IIP I'YP1f,tisx,
<br /> IA', BOAK) OF 1KAJAIM ATION U9,1' IA1f CI1f 13F ACCOUNYIP NUMBER N%mu r IIt'
<br /> .. r.ntc;vour Board of Fqualizc,0el (1301?) f,51,storage fee account numtwr whic1i ,,' requircd N ore j.".", k,c t, €
<br /> caf> be gi.>.=ccs ed. Registrafiw4hthe ail: will ensure at x,t vox will receive ,; :}ns t€,city ,_n _ rct ( Itir @ . n r.of th c:
<br /> 5Ck.4SJfa (0 mills) per gallon fee, due car. the number of gallons placed In your ac:S'1,r. `Ybe 13CfI, .,,1 c,nt E. ,nw,:<,ti_ t.,e:att t E"om
<br /> calf the sberage fee sea returns will not he sera_ If yctts do not have anaccount number r with she MOE ow clu h t m'n
<br /> questions regarding tine fee or exemptions, please cif the BOE at 916-323-9555 or write to the k.fll' _aa he
<br /> Board of Equalization, En-vironmental Fees Unit, P,0c Box: 1142879, Sacramenne, CIA, 94275=_00C)l,
<br /> , PFFROLEUM UW FINANCIAL I,S NSIB (M 1'TIP COMPLIr1'I )
<br /> c.,,niiy, the taetl od(sl used by,the owner and/or operator in a iectin the FII de nij and State (#T e ia.<tl c.tvonsl➢;t,iv
<br /> "f..=,5E; owned by any Federal or State agency are exempt t l a"C.m uhfis
<br /> L LEGAL NC1'1'1F1(' .f`1ON AND 13,111 C1 ADDRES.%
<br /> Check ON'ON'P, BOXfor the a dvess titer will the ,lst.d for BCal'f-f 1`1XI L AND B111,IN 3
<br /> SPPLICAC'MUM'SIGN AND "tNFE'111R,FORM AS f W11111
<br /> !N,", R(.IC".f'IO FOR'ME'LOCAL AGAIN,. S
<br /> Pit. county and jurisdiction numik,c rs ars: predetermined and can be obtained b"; calling the Statt. Board
<br /> facility number maj, Iac assigme l by the local ag tncy< however, this nncaanatser must be ,numiefic€l av Cannot em x
<br /> atph:>abeticxai. If the local agency retew, the Stale Board to assign the faciletr ner"ibe , t,iralsc lca'c ; ' ,.t;'r.
<br /> 11111 IS 1171F RESPOINISIMMY OF'111B LOCAL ACII?N011 '1'11"A I"INI SP 3 .M 7`111s Flot('1 1IF-11" Wy V 11"I.,sfr f
<br /> ,AU-'CURACY OF"1111' I FORMAI'Iftl ', 17HIS AaPLICY'VI-If N 0kNN(YI Ill' f'IIf.If,I;VS11,) .fl 1311"I 801E ACCOIJUNN,
<br /> NUI"IEFR ITS NO`I' MILLI,I) CN" ""1A1I, LOCAL GENC: IS RESPON IIIIXT FOR Ilff''C,aaslt'I, >Il a ; f "t-IME,
<br /> ."at HSIC.'.;'°USE ONINf UNFORMA71701c IM AND FOR POFW RDING ONE I C,kh"l A AND
<br /> ,ARSfIfYMUMD FORM "B"(s)1V0 I1M 18t 1 'ONI t iG I3IMI"Ssv
<br /> I` °WC:FC 1 1° A,
<br /> C,/()sir aE
<br /> P'0IIO2
<br />
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