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1NSfRLJC'I7ONS MR COMPLETING FORM W
<br /> GENERAL INSTRUC-ITONS:
<br /> I. One FORM "A" shall be completed for all NEW PERWRI,`% PERMIT CHANGE S or my FACiury/sn'r
<br /> INFORMNFION CHANGE-S.
<br /> 1 SUIS I' ONLY ONE (1) FORM 'A' for ai Fd��fity/Sitc, rcp,-dk!ss of the munber of lanks located at 0w .tkc,
<br /> 1 This form should be completed by cithcr the PEKMWJ-`APPLK�ANF or the LOCAL AGE.NUY UNDI'R(;R()1-,ND
<br /> TAN-K, INSPPX-[Y)R.
<br /> 4. flicase type or print clearly all requested information.
<br /> 5. L,1,se, a hard point writing instrument, you are making 3 copies.
<br /> 1'OP OF FORM. 'MARK ONLY ONFI ITEM'
<br /> Mark an (X) in the box next to the item that best describes the reason the form is, being comricted.
<br /> L i4maurypsnE imx)RmN.noN &- ADDR (MUST BE COMIAs,
<br /> 1. 'Record name and address (OyNical,locaticn-,, of the under-rOand tank(s).
<br /> NOTV: Address MUST have a valid j-')hysil.'al location including city, state, and zip code.
<br /> P.O. BOX NUMBFRS ARE NO'i-,AM!VFAB1-K
<br /> Include ticarest cross street and of the operator.
<br /> 2. Phone number must havc,� area code. ii the night number is the same, write "SAME" in proper locanon.
<br /> 3, Check the approp r* * for TYPE OF BUSINESS OWNERSHIP (ex. COILPORA'IION. INDIVIDII-AL c7tc.)
<br /> 4. Check, the approp i te bq5xfvr TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check- the box marked 'AT'S".
<br /> 6. Indicate the NUIMBER of TANKS at this srl'E.
<br /> ,7. Retord the P.T.A. ID # or write "NONE" in the space provided.
<br /> 13, PROPEIrt"Y OWNER UVORMNtION&ADDRESS (mTJ,5r 13E COMPLE-n,,D)
<br /> Complete all items in this section, unless all itemi, are the same as SF(7116\� 1"; if' the sanic- write ',SAAl-,. AS S1`V17
<br /> shin sc(lion. Ile sure to check PROPERTY OWNERSHIP IPEbox,
<br /> 111, 'FANK OWNER JNFY)RM1VF1ON & ADDRE&S (MU91' HE COMPLE17f))
<br /> Coninicte all items in this section, unless all ricnis are the, saine as SECF10N 1; If the sartic, wtitu 'SAME AS Sritl
<br /> this Be stare to check TANK OVIMIRSIRPTYPE box.
<br /> tv. BoAm) OF EwAuzATToN Lj,r sToRAcw 1117E,ACCOUNT NUMBER (MUST 13E complima))
<br /> Fritc,r your Board of EquatizatJon (BO E)'U'51, storage fee account number which is required before yOut permil
<br /> can be frroccssed. Registration with the BOE will ensure that you will receive a quarterly storage fee retun) jn tic.
<br /> SO.006 (6 mills) per gallon fec, due on the number of gallons placed in your USTS. The 1301" will code per�ons cxcnipi hom
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the 110L oii' vou have: an,,.
<br /> questions regarding the fee or exemptions, please call the BOF at 916-323-9555 or write to the BOL at the foflmving,
<br /> Board of Equalization, Ittvironmental fees Unit, P.O. Box 9428779, Sacramento, CYN 942119-0001.
<br /> VPFTROLEUM U,51'FINANCIAL -MU51-BF.compl'urru))
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State,financial responsibility
<br /> requirements. US`rs owned by any Federal or State agency are exempt from this requirement,
<br /> V]. LUCYAL WITTTICATION AND BUJINGADDRE&S
<br /> Check ONE BOX for the address that will be used for B01'II LEGAL AND BRI ING N(YFl1,ICA'I1ONS.
<br /> APPI1CATVF MUST SIGN AND LATE 711F,FORM AS INDI(WMID.
<br /> IN9FRUC'lTON FOR TIM LOCAL AGINCIRS
<br /> "he' county and jurisdiction nunil?crs are predetermined and can be obtained by calling the, State Board (916)731),11:121, 'Thr
<br /> i"wifity number may be assigned by the local agency; however, this number must he nunreHcal and cwlnot cnnlal-, wv
<br /> allibaberical, If the local agency prefer-, the State Board to assip the facility number. PiCaSe leave it ;;tank.
<br /> rr US 1111i RMS PONSIBIIXI'Y OF'nfli LOCAL AGHNC'Y 'IIINI' INSPIRAS'1111!EA(-IIXI'Y 'IT) VERMY'111E
<br /> A(X-'IJRA", OFTHE INFORMATION. '1111S APP11CATION CANNOT BE PROCESSED IF111P WE ACCOIJAW
<br /> NUMBER IS NCYI'FILLED IN, '1111F LOCAL AGENCY IS RE-SPONSIBIJ7 K)R 1I11t, COMPI,11,-110N OF 1111T,
<br /> "LO(AL AGENCY ITSE ONLY' INFORMN170N IX)X ANI) FOR FORWARDING ONE Ik)RM 'A' AND
<br /> 'AW)CIA770 K)RM "B"(s)TO THE F011,0WING ADDRE-ZZs_
<br /> KFA71'I3 OF CALIFORNIA
<br /> STAn;,WA71133R I(ESOURCF—S MNFROL ROARI)
<br /> C/o &W.Tu� ,
<br /> I3ArA PROCTO SIW; CTWITR
<br /> P,O, BOX 527
<br /> PARAMOUMr, CA 90723
<br />
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