|
INSI'RIA-11ONS FOR CONIT'LL'i t.11t i 'A'
<br /> GENFRAL INSMUMIONS.
<br /> 1. One F(WM 'A" shall lic, completed fordl NEW PF ITS, 'MITC11ANGEN or ant FACILITY/SITF
<br /> CIIANGF-&
<br /> 2. -i )NF (1) FORM W [',i
<br /> a !4cjlitv/Site, reg" 'I 111c nilinbci of 1,11"lo, lo"a""i
<br /> Sl �
<br /> 3. Thi, jonn s,IaoLtI6 be Completed hy. cillicr 11w III 0,c, LOCAL AOFINCY
<br /> TANK INSPIX'FOR.
<br /> 4, Please type or print cleariv all requested information.
<br /> 5. Use a hard point w-riting instrunient, you are making I copies,
<br /> 01"FOR-W "MARK ONLY ONI:," r1'FM"
<br /> Mark an (X) in the box next to the item that best describes the reason the fbrm N heirig'coa ipleted.
<br /> L
<br /> 1. Record name and address (physical location) of the underground tank(s)_
<br /> NOTE: Address MUST have a valid p;lysical loailion Including city, stale. and Yip code-
<br /> 1'.0. BOX NUMBEWS ARE N(Yr ACCIFITABtli-
<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 "SANTE" in j)roper locillior.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERST1111 (ex. CORPOI2A7ION, INDIVIDUAL err.;
<br /> 4. Check the appropriate box for TYPE OF BUSIMSS,
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands. check the box inm-kcd -0-,S'.
<br /> 6Indicate the NUMBER of TANKS at this ME
<br /> 'T Record the E.P.A. ID # or write "NONE" in the .5pacc provided.
<br /> OWNER INFORM)MON & ADDR.E&S (MUS71' BE' COMPLEM7,D)
<br /> Complete all items in this section. Unless all items arc the same as SE(MON 1: if the same, vTile *SAME"AS STIT."
<br /> this section. Be sure to check PE OPEMY OWNERSHIP rrym.,, box,
<br /> M. TANK OWNEM IN17ORMNIION & ADDRIWS (MUS T` BF COMPIX,-IM)
<br /> Complete all items in this section. unless all items are the same as SIX.71710N .1; If the same. write 'SAME AS SFI'E
<br /> this section, Be sure to check TANK OM4FNF.PSTT7f1 INPE box.
<br /> Its. BOARD OF EQUALIM.11ON USI'S'FORAGE FEE,'A(-(.'OUrqr NUMBER BY, COMP1,1ri-13))
<br /> Enter your Board of Equalization (BOE) U517 storage fee account number which is required before your permit npplwati:-n
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in rcporung wt.
<br /> $0.000 (6 mills) per gallon fee due on the number of gallons placed in your USA's. T I he BOE will code persons c,.cinpt 1'roin
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the 1301', or if' ycw 1mve, anti.
<br /> questions regarding the fee or exemption,;, please call the BOF.at 916-323-9555 or write to the BOU at the following address.
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento. CA 94279-0001.
<br /> v. Pumou.?Um usr viNANcw, RispoNsumny (mbsr Bu cOmmtrivi))
<br /> Identify the method(s) used by the o-wrier and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. UST's owned by any T`edcral or State agency are exempt from this requirement,
<br /> VL IJTGAL MY11FICATION AND BUJING ADDRESS
<br /> Check ONE IX-)X for the address that will be used for B0111 LEGAL AND 14111ING N(T11FICAI1ONS.
<br /> APPLICAW MUST SIGN AND D/VM-111E FORM AS INDICc111:11),
<br /> IN51MUCHON FOR*111E LOCALAGEMMS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242L The
<br /> facility number may be assigned by the local agency" howevrr, this number must be numerical and cannot contain art;:
<br /> alphabetical. If the local agency prefers the State hoard to assign the facility number, please leave it blank.
<br /> 1`17 IS'I II, RINT`f)NNS'TBHX1T OF ITH!LOCAL AGENCY THAT INSTV"TTS'1711i FACIIJI'Y TO Vt!jwty'111171
<br /> ,-1 "-C",� ",F MOCE SED IF 171F BOF ACCOUNE'
<br /> A(X7URA(N Oil "I I P INFORMATION. `1THS APPLICATION CAN' -
<br /> Nt,-MBER IS M)I 11,,LED I.N. ME WCAI,AGINCY IS JWSPONNN 01 Of,,, 11111 HIION Olt'1711i
<br /> 'LOCAL AkiLNCAUSP.' ONLY* IN FORMAI" BOX AND FOR FORWARIDINO ONU FOWM 'A" AND
<br /> ASSOCIMED FORM 'B'(s)TO 111E,1101,1,10WENNG ADDRT'SS,
<br /> SMVIE OF CATIFORNIA
<br /> SIWIT, WATTR RFSOURCI,,, Y,41'80i, 00AW'
<br /> C/O &W,lu-'ws,
<br /> DXFA PROCMSSING C1WI'FR
<br /> P.O. BOX 527
<br /> PARAMOUNIF, CA 90723
<br />
|