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IMSFRUCTITONS 17O t C,C)MPLEFIIV , IORM 1A"
<br /> ;. t 3 w, „",')RM A" sh aH be completed for all .NEW PERMIIN, PF.Rmrr CIIANGnS or any IEAC'[F,I"-y/sI" "
<br /> 04VOILMN11ON CHANGES-
<br /> 2, SUBMYPONLY OSIF (I) FORM "A" for a Facility/Site, regardless of the number of tanks lova and at>thc, site.
<br /> 2. This fat m should be completed by either the PT;TLMIT APPLIC°AM'or the LOCAL AGENCY UNDIilZCSICCIE.IND
<br /> 'LANK INSPIR11 IL
<br /> Tlr to t,,-pc €r paint clearly all requested information,
<br /> t1 c, a hard point writing instrument, you are making 3 copies.
<br /> I . she
<br /> "MARK ONLY ONE I'FE'vf"..:...
<br /> ;n'k an (X) in the box next to the item that -best-describes the reason the form is being; completed.
<br /> L FAC'II,IIT/SrII3 INI-MMAADDRESS ( US`r BE C',C MPLIr;'I'E7I3)
<br /> 1. Record name and address (physical location) of the underground tank(s).
<br /> NO'M Address MUST have a valid physical location including city, state, and pip code.
<br /> P.O. BOX NUMBERS ARE Nur Aca wAII i
<br /> Include nearest cross street and name of the operator.
<br /> 1 Phone number must have an area code. If the night number is the same, write SAM in proper loca€tion:
<br /> ,3. Check thy`aplropriate b6x for TYPE OF BUSIN SS OWNERSHIP (ex. CO PORA'I ON, INDIVII)UTAL. cl(n)
<br /> 4. Check. the appropriate box for TYPE 01" BUSINESS.
<br /> 5. If Facility,/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YLS",
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E,P . ID # or write "NOISE" in the space provided.
<br /> II. PItCII"ERFY OWNER INIX)RIVIATION& ADDRESS (MUST BE COMPI 'I $))
<br /> r
<br /> C;ornplete all items in this section, unless all items are the sante as SEC`I`I0N 'l; if the sante, write 'SAME AS srnr * ,rcross
<br /> this section. Be sure to check PROPERTY flWNERSHIP TYPE box,
<br /> HL TANK OWNFR INI^C) T$£IN Vit,ADDRF&,s (musr BE cC3MI'LF?'Ilm) btti.a
<br /> Complete all items in this section, unless all items are the same as SEC`TION 1g If the same, write"SAME'.AS srn, acre=
<br /> this section. Be sure to check'.I'ANK OVAWJLSIHP SPF?box.
<br /> M 113OF7 E0UA :rZX1'7C) J T S OCyE JqiI?rAC:C't)t.7NT F (MCT L`BY, COMPLE71M)
<br /> Enter your Board of Equalization (BOE) € S`p storage fee account number which is required before your permit application
<br /> cast be processed. Registration with the BOE will ensure that you will receive a quarterly stag-age fee return in reporting the
<br /> {I.CtC)b (6 mills) per Callan fee due on the number of gallons plated in your € STs. The BC3F, will code
<br /> ..,persons exempt from)
<br /> paying the storage fee,so.retctsrais waif 9tot be sent. If you do not have an account number with klti.';IICIE I r,41,06 g ave agt}'
<br /> questions regarding the fee or exemptions, please call the BOE at 93.6-323-9555 or write to the BOE at the: follcrrvina €ddreas.
<br /> Board of Equalization, Environmental Dees Unit, P,O. Box 942879, Sacramento, CA 94279 1Qh -," � �a"�,
<br /> V. P I`2(3I.EUM US-I'.FINANCIAL RF,%PONSIBILrrY (MU,31'BE C.OMP1,011TD)
<br /> Identity 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 /> VL LEGAL NC3. .,CATION AND 3111INCI ADDRESS
<br /> Check ONE 13OX for the address that will be used for BO'111 1; ANIS B11,11M, IsIMT14CA11ONS,
<br /> APPLICANF MUS"I'SIGN AND I)XIM 1111H Ik)RM AS INIIIC/O1311
<br /> 1 ,I'RU('I'ION FOR TIIF LOCAL AGENC"IFS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 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 the State Board to assign the facility number, please leave it blank.
<br /> rr IS'I'IIE MSPONSHIHIff OF 1111E LOCAL AGINCY 71TIMI I:NSISE I TIllt F° CTI,X Y"I`O VERIFY IIIb
<br /> ACCURACY OFTHE IN1101 TlOM '11IIS APPLICATION C.ANWYI'LIF PROCTl,SS13F) IFTHE MM AC:C;CIi.NI'
<br /> MBF IS N()T F'IILF?I) IN. 'I;LI°, LOCAL AGINCY IS RINPONSIBLE TUR'1 COMPL TC)N OF TXIE
<br /> *LOCAL AGENCY USE£)TSL` ° A-116N 130X AND FOR FORWARDING ONE FORM" "�
<br /> A.WMCIAITH7 PCO M 'B'(s)TO 11,IE MI-LOWING AD RI°S.a.
<br /> I' IE OF C,AC,FF ORNIA
<br /> f9 WIE A°I13R RE—S URC"F_S I.`ROI,BOARD
<br /> DATA PROCESSING Clq"IEM
<br /> gP.O3 TigOX®y 5p2�7g CA
<br /> 90723
<br />
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