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11 5,1 CI1O S FOR COMP W1 17ING 17O *fig
<br /> GENERAL IN 1'IC13C1HO S. '.
<br /> 1. (Arae FORM "A" shall be corn®r letcd for all NEV 111?C ns, m,,.R YI` C;11ANGES orany a"ACIVI°tN,zSTIT
<br /> INFCtRM,N110N C'II NGF,S.
<br /> L±UBM l' ONLY ONE I) FO 'A' for a I'idlity/Sire."ic:gard! ss of ?tte rwnli r of a<anks i<c�at€,:9 m H111 _ <;-
<br /> This-ft)rrn should be =com ted by either the PI=;I£M11' APP11C":AW or Elie )CAL AGI NC: L;1^iI I R(iP,', `I
<br /> TANK INSP IC`I'Clll
<br /> 4, Please type or print elearly all requested information,
<br /> 5. Use a hard point writing instrument, you are ranking 3 Copies. "
<br /> TOP OF FORW 'MARK ONLY ONE I`'I~: "
<br /> mark an (14) in the box next to the item that best describes the reason the fi'arin is heing ccanplc.ted.
<br /> 1. It,AC3Lr1'Y/SFF l l 1. I]O D1?RKS S ( US-F BE CSR t'I..TIi`13Ef)
<br /> "l. 'Record name and address (physical location) of the underground tank—(s). "
<br /> NC;''1"E Address CS11".ha„e a valid physical location including city, state, and zits cinder
<br /> P.O. BOX NUMBliMS ARE WYI,' ( li«, M BIJ1
<br /> Include nearest cross street and naanae of the operator,
<br /> , Phone number must havsits-' iia code, the night number is the same, Waite "SAtML,. in proper l)
<br /> C'.heck"th aappr€3iaiate Brox fd`I"YPE OF BUSING OWNERSI41P (ex. CORP(' RATION,ININVIDI-AL, etc,.)
<br /> 4. Check the appropriate, box forTYPE OF BUSINESS.
<br /> , If Facility/She is located within an Indian reservation or other,Indian trust lands,efiectk the box nnarrked
<br /> C?. Indicate the NUMBER ofTANKS it this SPIE,
<br /> 7, Record the E.P.A. ITS # or wiite "NONE" in thespace•provided, —..v
<br /> L PROPERTY OWNER 1 1 ) #'” k t ADDRESS (Ai1J S 1 BE C'C3 lei l'l l3l )
<br /> Complete all items in this section, unless all items are the same as SI C°1`I0N t if the same, write''SAME AS SFI I's` ra ar,s
<br /> this section. Be sure to check PROPERTY OWNERSHIP P box,
<br /> III, TANK OWNER FO ]IoN &Al I.31 Iv ,(musr BE co i.,urf l))
<br /> Complete all items in this section, winless ail items are the sarnse as SE(7110N ON'1,: If the; wane. write, ISAME AS Si"I1.
<br /> this section. Be scare to check TANK Cl C: '> '1' PE box.
<br /> IVBOARD OF EQU ALU.. ,`1`CI USr STORAGE 51!ACC;K U Vr NUMBER(MI JS if 13IiCI P.1=I"o)
<br /> Enter your Board of taa,utalizatma (I30E) UST storage fee account number which is required before your permit op .., .,son
<br /> can be processed. -Registration with the BOF will ensure Haat you will receive az quarterly`storage fee return sa rep:., r,- fl—
<br /> �t 000 (6anills) per ;cellon fee due on"the nusztber sof gallons planced in y€yur USl"s. 'flier 130El will code perso.tn,, ac-ra,pa t.�r,an
<br /> ixefi ng the storage fere so returns will not be sent, If you do not have'an aacco u nt number with tare€ OV or if'you any
<br /> questions regarding the; fee or e ernnptiotns please caul the BOB at. 916-323-£9555 or write to the 110171 at the fool win, "ddr s;<
<br /> Board of fnjualization, l,xrvironrnnental Fees Unit, P.O. Box 942879,Sac,rantento, CA 9,1279-000L
<br /> yr ISI,,,nk i,i',, 1 1:1 i"IilNt N(,,i ,n RItaSPCEmSIl311.<1`l° (mu "IIE,C`.oI'E1unu))
<br /> Identic'v the method(s) used by the owner and/or operator in,meeting the Federal and -State financial responstbifi=r
<br /> requirements, US`Fs owned byany t'edcral or State agency are exerapt front this`respiirennew.
<br /> 1. LEGAL N(Y110CA'DON AND I1111. ING ADDRESS3
<br /> Check ONE BOX for the; address that will be used for B0171'L1W3 ;AND 1311 I £1 N(YI"l1tl ` °l"10Ns.
<br /> APPLICANF MUSf SIGN AND Dfl"I.1'11E 1URM AS': N(WIE .
<br /> INEvI" U(717ON FOR 1111LOCAL C'slt,
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling; the State Board (916)739-2421. 1"he:
<br /> facility number may be assigned by the local agency; however, this number must be numerical and catnnta contain any
<br /> aaiphabeticah _If the local agency prefers the State Board to assign the facility number, please leaves it blank,
<br /> IT IS 17113 RE—SPONSIBIT.TrY OF171E LOCAL AGENCY 11INI' INSPEC"1' '171E FACJLrJ'Y TO V11,R111y"Pills
<br /> A(X,'URA('Y OF THE ORMN11 I '17-11S APPI 1f: I°O (:ANNOT BE PROCESSED SED TIS 77111 DOE tAC:C",)UNP
<br /> 1 NBER 1S_NOT 141LI 3 IM '1I1E I.()C:, I.AGENCY I4 RINPONSIBLE FOR11W C OMPI..fnIt l OF THE
<br /> 1,OC A.G ;dqC USI?-(:) I:Y" TIOILUNFION BOX AND I'sOR IsORWARDIkO ONE 11ORM " ".AND
<br /> AS-SO `114 O W(s)TO THE, T111A) NG ADDREss.
<br /> S`rA11? OF CA11FORNIA
<br /> IgFA II f,WKIER RE SC3U C:E C L WARD
<br /> c/0 smi'mps, .
<br /> P 0. BOX 527
<br /> P .0 £31 I "1, CA 90'71
<br /> rt,s
<br />
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