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. . x tiw".a, M^'# :Sd: 7 INSTRUCTIONS FOR C_OMPLE`IING FORM *A* GENERAL INSI'RUCIIONS. FORM. "J1'" shall be completed for all NEW PERMITS, PERMIT CHANGES or any I?A('lI.C!'1'/Sfl'I's 1 _ 1tV1I0N CHANGES. SUBMIT ONLY ONE (1) FORM *A" for a Facility/Site, regardless of the number of tzmks located at the site. sl� ild be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNI FR(;R0t1`VU 'TANK INSPECTOR. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM_ "MARK. ONLY ONE ITEM" I, an (X) in the box next to the item that best describes the reason the form is being completed. 1. FA(3I.I"I-Y/S1TF. INFORMATION & ADDRESS(MUSSY BE COMPI.I IFF) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT AC CEP ABII! Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location. 3. Check the appropriate box for"TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL.,, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YFS". 6. Indicate the NUMBER of TANKS at this 3ITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided, ' H. PROPERTY OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write ",SAME AS SI71V across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. 'TANK OWNER INI'ORMAlION &ADDRESS (MUST BE COMPLETED), Complete all items in this section, unless all items are the same as SECTION 1; If. the same, write "SAME AS sm.* across this section. Be sure to check TANK OWNER.SIRP TYPE box. IV. BOARD OF EQUALIZATION UST.STORAGE TIS ACCOUNT NUMBER(MUST BE COMPII 11113) Enter your Board of Equalization (130F) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOF will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOF, at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE C:OMPLLrI'ED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BHI ING NCXIIFICATTONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGFNCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 'The facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. IT IS TIIE RFSPONSIBBI'1'Y OF THE LOCAL AGENCY TIIAT INSPECTS TILE FACILITY TO VIUUFY TILE ACCURACY OF THE INFORMATION. TILLS APPLICA"ETON CANNOT BE PROCESSED IF TILE BOE ACCOUNT" NUMBER IS NOT FILLET) IN. TILE LOCAL AG124CY IS RESPONSIBLE FOR T'HE COMPLETION OF THF; *LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "13"(s)IT) TI1E FOLLOWING ADDRESS. + STATE OF CALIFORNIA STATE WAIRR RESOURCES CONTROL BOARD C/O SWE14-P 5. DAI`A PROCTiS.SING (TW1131t P.O. BOX 527 PARAMOUNT, CA 90723 1