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10
<br /> �.sl.'_ l.4 ,_,ra?pFeted atl i mIC�lb� C7S or any FAC;11.rl /SITF .
<br /> r., S€.aaW11' fiN[:Y' ON1I(F) FORM »A Fora t�acility/Site, v-g ar ;::ss of the number of tanks 10 aied at the 1i1c,
<br /> '=gas form should be x_r pi ted by cstEtea the FN3C ar the ID€ 4CAGENCY L � }l �E �( li 7R�� I
<br /> 4, oyne oneria° print clearly= all ieo e,4e .. information.
<br /> 3 h,,=r4 ,..in! r'ritutg instrument rola azre snaking;3 cop.ct;,
<br /> _V07' TV 'NIAPI'K ONLY ONE r1lbW
<br /> < , (XI, it 1ox next to the item that b,",st describes the rea.r,,n tilt form is heing completed.
<br /> F, "/SDM INF
<br /> f➢FC IFC fa7313 I?S�S ( @1`�1 BEC"t3A F$1.,7.,I"°,I))
<br /> Cl.,ord k>aa,.o and ad&css (physicalof the umk(s).
<br /> �.
<br /> .i,. � Ma;, ...I ,I' have a melte s�,r,,:a;a�al location rtt4la�lrny, crate, and arp code.:
<br /> P,C) .?CSX i'°1Ifa1BFILS AIr1. .rf.""`AC:C 'J' € J
<br /> l;c cle nearest crass street �r.,_ nsmic of the operator,
<br /> a..,r;r.er muvt have an area erotic, If the night nurnber is the sarne, write 'SAN'll" its proper location.
<br /> Check ,.fes api)ropriate box for°,FyyYPEOl" B SS^SSS OWNERSHIP (ex. CCII�II`C)RNTIt3N, IN DIVII31?AL cat.;
<br /> .ck tla€. �appropxrictc ho% For. TYPEE OF 1331 Si Ei S&
<br /> If Fatal€t;y/Sne is located within an Indian rescan>aticrt or other Indian ;mast lands, check the box niairkecl "YE'S",
<br /> S",
<br /> r,. In is aie the NUMBER of J'ANKS at this SPIE,
<br /> Record the EYA, ID or write 'NON " in the space;;provided,
<br /> TL PROP11rC'1Y CYWNER INFoRMSnON&ADORNS ( usr BE C O L r'[d)),
<br /> E.za.,cte bat nciags in this :section, unless all items are the same as SEC:"I"ON t; it the same, write 'SAa F' AS Sl'I'Fs" ,ict xs
<br /> ,_.> cecii,art, Besure, io check. PROPER' OWNFRSLTIP 'I'S P box.
<br /> III, '.AN O I°IF',F1 INF ORMA°17014 8- ADDRESS (MUS1' 1317, COMPIJI11[3)
<br /> Con"plete all items in this section, :artless Gait items are the same as S1-1C"Il0N 2, If tine same,, tx-rite "SAME AS ST-11
<br /> this, scctiom Be sure to check 'rANK C1 M S IP'1 IIii box.
<br /> M BOARD OF 1390D L.YZA''1€7 US`r Sr0RAGR T,,F ACCOu I'r NUMBER MUST BF C OMPT. 17F,1.}
<br /> "<ra, _ra:your oar Registration wit'I�(BOE) IiS`' storm fee account number which is required be.fnrc your perms apph .,nio t
<br /> I r�r t� your Board est`Equalization
<br /> the BOE will ensure that you will receive a quarterly storage fee return in rcpt>rfin, the
<br /> S(.Cltfi (6 mills) per gallon fee daze on the number of gallons placed in your US'Fs, 'I'he 13(1 _ will code persons exempt from
<br /> 111at, storage fee say returns will not be sent, If you do not have an accounts umber with the.BOE or if you have ani '
<br /> rvgarding tlse re° or exemptions, filtaase call the BOE at 916-333-9555 or write to the BOF at the foilowin" _+ld] 411:
<br /> Board of Equatrration,1'nvironniental Fees Emit, RO. Box 942879, Sacramento, CA, 94379-0001,
<br /> , p"'F s"'1 a. LVI"el UC 3`FINANCIAL RJ.,iSPONSIB1LFPY (MOST BE COUPE,IrF l)
<br /> at,_,.r,ty the rasa=od(s) used by the owner and/or operator in meeting; the FtAe:ral and State financial responsibility
<br /> .,h,F; xrartts. E,Sns owned by arty Federal or State al;eney,are exempt from this requirement
<br /> V1_ 1. FE: I, Y11lrlbeA11C11S'AND 13111..1 CS Ar?IS1 �S
<br /> Ch€sell ONE BOX for tile, address that will Fre used for 130171 IXXIAL AND BUJING NMIRCKITON&
<br /> AP1S1 C'A1 F CxSs,.i' I'SIGNN AND DIVM THE, FORM .S . ICft1"i"1).
<br /> I SCFI ,C H FOR 11-M LOCAL AGIM..311,S
<br /> t h, =tart-; and jurisdiction nu nhes:s are predetermined and can he obtained by calling the State Board (916)739-24121. the
<br /> facifily rMinber may he ascigue.ct by the; local agency.: however, this slumber must be numerical and cannot contain any
<br /> alp aine¢ical, If tree local ardency prefers the State Board to assign tate faeifsty number, please leave it blank.
<br /> 11 IS'FII1s ISPO SIF3r X]p OF' Hi LOCAL AGENCY 17IM' INSPEC:1 'I"IE FACILM 7'0r :- 171F,
<br /> A.t...C1—BU C`Y OF'111F II I ORM-1`I ON. 'FTHS APPI..r(WrION CANNO'I"UF PROC,F SSS. 3 IF 77W DMI4AC;€OUNI'
<br /> lel..+Mr1I.:.R IS Is,`CYT' F111.1d) ML 71][Il LOC::.,r`1L AG a. AY IS ROSPONSIBLE.MR'r E t",t MPLF1rFC`N 017 MIT
<br /> "F.OQXL AGENCY USE ONLY'" 1I^7Irf3F A'F°1C11s1 B€ A ]FOR.FORWARDING CF Fs FORM "A"AND
<br /> ASIS$C'IAMy 17OR "63"(s)'I'0 `I'I11 FjOLI,C) rINCi .SDDFLI$SS.
<br /> ffCF Safi
<br /> 11,6VIA PROCESSING f FQVMIC
<br /> 11,0, BOX 527
<br /> PA11AMC7LT ; CA 90
<br /> r
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