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INMUCIIONS FOR COMPLE'ETNG FORM"A"
<br /> GINFRAI..INSF RU('ETONS:
<br /> 1. One FORM "A"shalt be completed for all N1?W I'llRMTIS,PERMTI'C""IIAW;HS or any FACILTF"Y/%rM _
<br /> INFORMA ITON CHANGES.
<br /> 2. SUBMrr ONLY ONE(1)1rt)RM"A"for a Facility/Site, regardless of the number of tanks located at thy cite.
<br /> 3. This form should be completed by either the PI'RMIT APPLECANr or the I ) AI..AGENCY UNDERGROUNDTANK
<br /> INSPEC7110R.
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF DORM:"MARK ONLY ONE?171MM}" i
<br /> 1. Mark an(X)in the box neat to th f,em that Fest describes the reason thl fDkI is�,irft
<br /> I F CIi,T /BETE' 1 I1 3RMA'ITON 8t Ai I IYI'SK4'(1vtU r"I' 3?C OMI'I.i rEri)) hal!f,, m I i t-e9 !
<br /> Record name and address(physical location)of the underground tank(s),
<br /> NO`1t:`-Address MUST have'a valid physical location including city,state,and zip code.
<br /> P.O.BOX NUMBER ARIx NOT ACCIN9.7ABIJ
<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 "SAMI?" in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNr-.T-SIUP-(ex. C ORPORA`I`0 , INDIVIDUAL,c:tc.)
<br /> 4. Check the appropriate b6x for TYPE 01'IiUSIM"ISS. 19
<br /> 5. If.Facility/Site is located on land within an indian reservation or other indian trust lands,check the box marked'YlS".
<br /> 6. Indicate the NUMBF,R of TANKS at this SITE:.
<br /> 7. Record the G.F.A. 11) # err write "NONE1" in the space provided.
<br /> EI. PROPERTY,(4WNRR INErOIPANfION&AEI RYISS(MUS-1-E#p,tL)(I�'I :I ? 'M' .�e.: j r.,Imo,y, #* "t: } r
<br /> 1. Complete all items in this section, unless all items are the same as SGC'I10N 1; if the same,write "SAME AS Srl[W across
<br /> this section. Be sure to check PROPI R'rY OWNI RSHIP'I YPE box.
<br /> III,TANK OWNER IM7ORMA'I7ON&AI3DRINS(MUSt'BE COMP1.1.1'I1 D)
<br /> 1. Complete all items in this section,unless all items are the same as SECFION I; If the same,write ".SAME AS SrM*
<br /> across this section. Be sure to check TANK OWNERSII.IP TYPE box. j
<br /> EV BOARD OF IQUALIIAITON UST S.rC)ItA(.1:?I1 3 AC( UAfC N 1G E}I�R(mysr t ?CX)MPLeftm)
<br /> r s' f 1 ,n"1),,
<br /> Tinter your Board of Iklualizration (130F3) Ilii I'stopp fee account number whit& is required before your permit application can
<br /> ( ` be Recessed.•1Rpgistrat ion with the 130E will en rc Ltat you will receive a quarterly storage fee return in reporting the$0.006
<br /> �Ci ntllis)'}�ct gallon fee due can the'number of ga lons`piaccd in your US'rs. The B01: will code persons exempt from paying the
<br /> 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
<br /> regarding the fee or exemptions, please call the 1.301.1 at 910-739-2582 or write to the BOF;at the fallowing address. Board of
<br /> Equalization, Environmental 1�"ees Unit, P.O.Box 942879,Sacramento, CA 94279-()Mil.
<br /> V. LEGAL NOr1TFI(WnON AND 13I1.I..ING ADDRFS,S
<br /> 1. Check ONE?BOX for the address that will be uscilor B(YIT-I LEGAL ,3I NOl G,i AON&
<br /> C ,
<br /> ;APPI.ICANY.,MUST SIGN ANI)DX17?'I M Ir)}MAS INI-ACKI-I" ,
<br /> INS"E'RUMTON FOR TI1E?LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the SiAte Boaid (0,16)739-2421. The
<br /> facility number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the facility number,please leave it blank.
<br /> rr IS-nwl REI:SPON IBIIXrY OF n iF.F()C A1,A(1E:NCY'ITIA'I'INSPrX:I'S THE FAC'EE,TTY 1`0 VERI11Y 111E
<br /> ACCURAC.'Y OF'11IIL IWORMA'TION. 11 IIS APPLICATION CANNOT 0,3E PROCT-SSID IF1111t BOE ACCOUNT'
<br /> NUMBER IS NO`F FILLET)IN. 11II1,LOCAL AGIWC'Y IS RI?SPONSIBI.Fi FOR'E3IFi COMiPLIMON OF"11113'IDC:AL
<br /> AGF.NC"f USE ONLY"INI"ORMA'I'ION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOC1A1131)MRM
<br /> "B"(s)'M 11IE FOLLOWING ADDRESS. � 4 �
<br /> 4IM1,1 OF C'.ALIFORNIA +_ c' V`► �, \ a
<br /> STA'T'E?WA'F`ER RESOt1RC:?s MN—FROL BOARD
<br /> C/O S.W.11.1?P.S. �s `
<br /> DATA PROCESSING(12MR ti
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA.99M � C
<br />
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