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INSFRUCIIONS FOR COMPLETING FORM `A!
<br /> GENFRAI. INS TRUC 11ONS-
<br /> 1. One 17ORM "A" shall be completed for all NE-W PERMIT'S, PERMFI'CJ1ANG1-N or any FACIffry/sriv
<br /> INFORMAFION CTIANGES,
<br /> 1 SUBM17FONLY ONE (1) 17ORM 'A' for a Facility/Site, regardless of the number of tanks located at the sitar.
<br /> 3. This form -,�hould be completed by either the PERMIT APPLICANT or the LO(AL AGENCY UNDURG1201.)ND
<br /> TANK INSPECTOR.
<br /> 4. Please type --,, print clearly all requested information.
<br /> S. Use a hard point writing instrument, you are making 3 copies.
<br /> TOP OF FORM:- 'MARK ONLY ONE- nEm"
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACIIXIT/Sh7E INfAdkMKJ1ON'&'ADDRESS (MUST BE COMPLU119))
<br /> 1. Record pante.and address (pbysical location) of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX NUMBERS ARE NOT AC(3iFrl*ABW-
<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 "SAME" in proper location.
<br /> 1 Check the appropriate box far TYPE O ' BUSINESS OWNERSMP (ex, CORPORAFION, INDIVIDUAL, etc.)
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A. ID # or write "NONE" in the, space provided.
<br /> AV, V
<br /> It. PROPERTY OWNER RVORMATION&ADDRESS (MUST BE COMPLE-W-D)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME AS Sn1' across
<br /> this section. Be sure to check PROPEWIT OWNERSHIP TYPE box.
<br /> III. TANK OWNER INFORMATION & ADDRESS (MUS`r BE COMPLMVID)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAMF AS Srni" across
<br /> this section. Be sure to check TANK OWN TJV9I1PTYPE box.
<br /> • IV._130ARD OF MIUALIZAT[ON UST SFORAGJ33 FTE ACCOUNT NUMBER(MUST BE MMPLFIIT-M)
<br /> Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of p1lons placed in your UST%. The BOE will code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the ROE or if,koxb
<br /> 0 �any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-32.3-9555 or write to the BO N' ar,,s-.,,,
<br /> E-ai the I
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 9428'79, Sacramento, CA 94279-0001.
<br /> V. PYTIROLEUM. UST FINANCIAL RESPONSIBILITY (MUST BE COMPIV-11313)
<br /> Identify the melhod(s) used by ihe owner and/or 6p'e'rafor in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> VL I.EGAI. N011MCATION AND BH1JNG ADDRESS C,
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BUTING N077II[CATIONS.
<br /> .APPLICANT MUST SIGN AND DATE TJJ-L,' FORM AS INDICATED,
<br /> INSIRUCMON FOR'IW,LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)7.19-2421. The
<br /> facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any.
<br /> alphabetical. If the local agency prefers tht, State Board to assign the facility number, please leave it blank.
<br /> rl'IS '1711V RI&STONSIBILM 01'111V AGENCY'IMT INSPECES'ITE FACIIX17Y TO VERIFY'DIE
<br /> ACCURACY OF T11E INFORMA110N. 'IIHS APPIACNITON CANNOT BE PROCESSED IF TT-IE BOE ACC'O(JTVl*
<br /> N't,! IBE IS N(TI' MIXED IN. 1111, LOCAF, AGIWCY IS RESPONSIBLE FOR`111E COMPLETION FII' 1E.
<br /> —11
<br /> IIAWAII A(;I,,*N(-',Y USE ONIN" INFORMA-110IN I-99X AND FORFORWARDING ONE FORM 'A"AND
<br /> -ASSOCILVIVID FORM TIIE FOUjOWING ADDRESS.
<br /> MWJT', OF CAIA'ORNIA
<br /> SFYVIT, WA'13,R [W-SOURCT-S CONI'ROL BOARD
<br /> C/0 S-W17-1-1.111S
<br /> DIVIA PROCI-SNING C-ENTITR
<br /> P.O. BOX 527
<br /> PARAMOUNT, CA 90723
<br />
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