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IN%-I'RIJC"IIONS FOR CO PLI.I111WRM'A'
<br /> taC?TI3R.�`a1,Il�l.`�I`ta'L3C;`I'Cf.bPddi:
<br /> 1, One FORM "A"shall be: completed for all NEW PERWIN,PE I'C:IIANG1I�rS or any IAC:ILTINISNI;
<br /> INFORMA`I"ION CIIANGI.-?&
<br /> SIII3MI1'ONLY ONI?(1)PORla W for a Facility/Site,regardless of the number of tanks located at the sit .
<br /> 3. This form should be completed by either the PI R;4Ir1'AFT11CANT or the LOCALAGENCY UNIX'::KGROUN `#'ANK
<br /> INSP 'OR.
<br /> .4, Please type or print clearly all requested information. j
<br /> S. Use a hard point writing instrument,you are making;3 copies.
<br /> TOP OF FORM: 'MARX ONLY ONE ZIIW*
<br /> I. IIark an (X)in the box next to the item that best describes the reason the form is,being completed.
<br /> L FACl1.r1-Y/SMi INFORMAMON&ADDRESS(MU9r BE(X)lV1PLYA14))
<br /> 1. Record name and address (physical location)cif the underground tank(s). �
<br /> j NOTE: Address MUST have a valid physical location including city,state,and zip code.
<br /> P.O. .. NUMBER ARS?N AC C;I 17ABI11
<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"SAM " in proper ton.
<br /> 3. Check the appropriate box for TYPE:OF BUSINESS OWNI RSIIIP (ex. COItPOYUVHON, INDIVIIA'AL,etc.)
<br /> 4. Check the appropriate box forTYPE,OF BUSINESS.
<br /> 5. If Facility/Site is locatedQ6 land within an indian reservation or outer Indian trust lands,check the box marked 'YES',
<br /> 6. Indicate the.NUN c 'ANKS at this SITE.,.
<br /> 7. Record the L TAP 11) # or write"3() l' in the space provided. 1
<br /> H. PROPERW OWNER INFORMA7 tON&ADDRF1&S(MU91'BE COMPI.1r11ID)
<br /> 1. Complete all items in this section,unless all items are the saute as SEC CION,1.; if the same, write 'SAMB AS SITE'across
<br /> this section. Be sure to check PROPERTY OWNERSHIPTYPE PE box.
<br /> �
<br /> ( � )Ill.TA OWNER IPgI�() A'I'IC)hI&ADDRESS R+II7SI'BECOI"I..I, 'iy'4I) �
<br /> I
<br /> 1. Complete all items in this section, unless all items are the same as SI C`fZC:N 1, If the sante,write 'SAME AS STI li' I
<br /> acres this section. Be sure to chew+ "ex,"-'rl i.R,SIHP' I E box.
<br /> IV BOARD OF EQUALIZAMON U.1;1"- 0:^kGE I1, (X)'Cllx3'I'NUMBER(F i 7<SI'III:C.CkMPLIXED)
<br /> k
<br /> Enter your Board of Equalization (1, USI'storage fee account number which is required before yopremit appligatipa can
<br /> t be processed. Registration with the 110E,will ensure that you will receive a quarterly storage fie icturn id refort'ing the
<br /> (6 mills)per gallon fee due on the number of gallons placed 1n your USI's. The BOE will code persons exempt from paying the
<br /> storage fee so returns will not be sent. If you do not have<n account number with the BOL.or if you have any questions
<br /> i regarding the fee or exemptions,please call the BOIR,at 916-739-2582 or write to the BOE at the following address: Board of
<br /> Equalization, Environmental Fees Unit,P.O.Box 942879,Sacramento, CA 94273-0001.
<br /> P
<br /> V, 1.1XIAL NO'ITFIC:A'I1ON AND BH.1JNG ADI1rRI dSS
<br /> 1. Ch' .k 61`4 'IIOX for the address that Wi l't>e used for IXYIII I;II.�.rAL'AND B111,NG NC)`M4(:A'I76N S.
<br /> t .
<br /> f
<br /> 't. APPLICJ'wr musr SIGN AND DA11 THE 13ORM AS IND'IeA'110. ; g
<br /> WS WA-tION FOR 11RRAOCAI.A�sI?.NOI:?S
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(910)739-2421. The
<br /> facility number may be assigned by the Ictal agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> ,-,"ncy prefers:the State Board to assign the facility number,please leave itfbiank, �
<br /> RESPONS1I311,17rY OF'II P Fl I OC'AI,AGENCY'I`isr iNspF;C rs'111E FACIII'I Y 1"0 VERIFY'Lim
<br /> 4C'C E.ititC I;'ITII;I,IsIIURMA'1 (01 '111IS AI'r'i,l(NIION(:AI' ICTi'IIIc PROCIISSIrI)IF111F BOE ACCOUM'
<br /> 1 tC
<br /> ,!k is I'll 11 ,113 Its. 11 W L 0NI,AGFN(Y IS RF-SP0NSIBII: FOR 11It,COMPLIT110N OF 11III*LOCAL
<br /> AgGEINt:Y L�g�Fs ONLY'II*IFORNIA'ITS;N I'3 ):X'ANTI I�€: R ITO ARDING ONE FOR 'A'AND AS,SOC 110 FORM
<br /> 1,I)LI,10WING ADI WFC',Tk,
<br /> SI"Ill; OF CALIFC)h"dIA
<br /> SriI13 WAI1ER I<t' 3tTRCI°S CO IROL BOARD
<br /> C/o S.W.umP.S.
<br /> DATA PRO(I?S'SWG C'ENJ°IT
<br /> P.O.PA)X 527
<br /> �. PARAMOUNT, C r1'31)723
<br /> i
<br /> t' I!
<br />
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