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0 <br /> 1W17RUCIIONS FOR COMPLE 1NG FORM "A" <br /> GENERAL INS'IRUCIIONS: <br /> I. One FORM "A" shall be completed for all NEW PERMITS, PERMIT'C.IIANGES or any 1{AGILI`T'Y/'n,E. <br /> INFORMATION CHANGES. <br /> 2. SUBMIT ONLY ONE(1)FORM "A" for a Facility/Site, :reg._rdlcss of the number of tanks located at the site. <br /> 3. This form should be completed by either the PERMIT APPIJCANI'or the LO(Al,AGENCY 1.)NDI1'R6R0t_N1) <br /> TANK INSPFA—,MR <br /> 4. Please type or print clearly all requested information. <br /> 5. Use a hard point writing instrument, you are making 3 copies. <br /> TOP OF FORM: "MARK ONLY ONE ITEM" <br /> Mark an (X) in the box next to the item that b+°st describes the reason the form is being completed. <br /> I. FACILITY/SITE RMAT[ON&ADDRESS (MU517 BE COMPL .TVD) <br /> 1. Record name and address (physical locatiot ) of the undergr oind tank(s). <br /> NOTE: Address MUST have a valid physi•al location including! 6ty, state, and zip code. <br /> P.O. BOX NUMBERS ARE N(7V ACCEPTBU <br /> Include nearest cross street and n e of the operator. <br /> 2. Phone number must have an area code. ii the night number is the same, write "SAME" in proper location. <br /> 3. Check the appropriate box for TYPE OI' BUSINESS OWNERSHIP (ex. CORPORATION, INI31VIDUAl., etc.) <br /> 4. Check the appropriate 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 "YES". <br /> b. Indicate the NUMBER of TANKS at this SITE. <br /> -7. Record the E.P.A. ID # or write "NONE" in the space provided. <br /> PROPERTY OWNER 04FORMA1ION&ADDRESS (MUST BF.. COMPLETIT)) <br /> Complete all items in this section, unless all 'items are the same as SECITON 1; if the same, write 'SAME AS SIIT:" across <br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box. <br /> III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME.AS STET;" across <br /> this section. Be sure to check TANK OWNERSHIP'TYPE box. <br /> IV. -BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER (MUST BE COMPIHIT-M) <br /> Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application <br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the <br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's, The 130E will code persons exempt from <br /> paying the storage fee so,returns will not be sent. If you do not have an account number with the 130E; 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 foil6wing address: <br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. <br /> V. PETROLEUM USI'FINANCIAL RESPONSIBIIIIY(MUST BE COMPLT fED) <br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility <br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement. <br /> VI. LEGAL NOTIFICATION AND BIIJ.ING ADDRESS <br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING, NOTIIIC/mONS. <br /> APPLICANT MUST SIGN AND DATE TTWF FORM AS INDICATED. <br /> N.STRUCTION FOR TIIE LOCAL AGENCIES <br /> The county and jurisdiction numbers are predetermined and can be obtained b_� calling the State Board(916)739-2421. Tltc <br /> facility number may be assigned by the local agency; however, this number must 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 /> IT IS THE RESPONSIB OF T1;IE LOCAI.AGENCY THAT INSPECTS 11II3 FACTUTY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. THIS APPLIC'A'TION CANNOT BE PROCESSED IF T'IIE BOE AC00UNI' <br /> NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR 111IE COMPLEITON OF TIIE <br /> "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE:,FORM "A"AND <br /> ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRFSS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/o&W.E.E.Ps. <br /> DATA PROCESSING CFNIER <br /> P.O. BOX 527 <br /> PARAMOUNT, CA 90723 <br />