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I IN,14;rRUC11ONS FOR COMPLE'll I OR* IV
<br /> NG F
<br /> GFINERAL INFO'Rf1,(7T10NS-
<br /> L Onw V()RM "A" shall be completed for all"NtrW PERMYI'S, PL'Rmrr 01ANGE-4;or any FACILITY/Sl"FI
<br /> INK)IMN110N C'HANGFS.
<br /> 2. SUBMrr ONLY ONF (1) FORM 'A7 for a Facility/Site, regardless of the number of ranks located at the sitar;
<br /> 3, "This form should be completed by either the PERMIT APPLICAmr or the LOCAL AGENCY UNDERGROUND
<br /> TANK INSPEX708
<br /> vsl or print clearly all requested information.
<br /> L-,,� a h4rd point writing instrument, you are making 3 copies.
<br /> -G,, 3RM: "MARK ONLY ONF.z num
<br /> an (X) in the box next to the itefiil,t t best describes the reason the form is being cornple6ed,
<br /> L FACILE11T/ .,,0WORMXfT0N,&ADDRESS(HEIST BE COMPLVfVD)
<br /> 1, Record same and address (physical location) of the underground tank(s).
<br /> NOTE- Address MUStl' have a"lid physical location including city, state, and zip Code.
<br /> P.O. BOX NUMBERS ARE Nar AccwrmuL
<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 locati6n,
<br /> bee
<br /> 3 bOx for'IYPE OF BUSINESS OWNERSHIP (ex. CORPOit/mON, ININVIDLIAL, cie,)
<br /> 41 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
<br /> 6. Indicate the NUMBER of TANKS at this SrfF,.
<br /> 7. Record the E, .A. ID # or write "Nt--)NE." in the space provided.. ,
<br /> IL PROPEKI-Y OWNER IMzORMATION&ALAI} SBS (MUST BE(X) -0V
<br /> Complete all items in this section, unless all items are the same as SEC 11ON I-, if the same, write "SAMF"A.%sm- a,ros.s
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box,
<br /> Ili. TANK owwm iNPoRmNnpN A,ADDRF---% (musT BF,compLL-1m)
<br /> Complete all items in this section, unless all items are the same as SEMON L If the same, write *SAM14"AS Sao across
<br /> this section, Be sure to check TANK OV EI !YPE box.
<br /> ,AVPOARP,- EQUA117A.179� ?.VST.r STORACYR FET.ACCOUNT NUMBER WW BE C!OMPLUI19))
<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 /> M006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. ne BOE will code persons exempt from
<br /> paying the storage fee so returns'4ill,,notbe"96t. If you do not have an account number"whh thB612--,or1f y6d4iav�e away l:
<br /> questions regarding the fee or exemptions, please call the BOE at 916323-955.5 or write to the BOF at the following addrcss:
<br /> Board of Equalization, Environmental Fees Unit, P.O. px 942879, Sacrantento, CA. 94279z0001"'
<br /> V. PErROLEUM UST FINANCIAL RESPONSIBIIXFY (MUST BE COMPL1r1TiD)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> iequirements. USTs owned by any Federal or State agency are exempt from this requirement-
<br /> VL LEGAL NC}1MCA37ON AND 111 Ca ADDR
<br /> Check ONE BOX for the address that will be used for BCrI`H LEKiAL AND B11JJNG N=FICA'110N&
<br /> APPIJCANT MUS717 SIGN AND DKrL1 17113 FORM AS INDICA113D,
<br /> IM'I'RUCIION FOR 11-W,LOCAL ACAFNCTF-S
<br /> The county and jurisdiction numbes are predetermined and can be obtained by calling the State Board (91(1)739-2421. 1he
<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 /> n,is nut iu%ToIu= of pul-LC}cm.A (-Y '11INII, INSPEXMS'171F EA(WIT TO VIUMIY 11ni
<br /> ACCURACY OFTHE INFO `FICIN. 719S APPLICKIION CANN(Yr RE PRO(TISSFD IF`111F BOB ACCOUNF
<br /> MJMBER IS NOT 1111,ED IN, 711E LOCAL AGENCY IS RESPONSIBLE FOR'nW,COMPIS,__0
<br /> *LOCAL AGENCY USE ONLY'AINFOR]ANNON_W*,AND FOR FORWARDING ONE FORM'7AiA`N&'1','
<br /> ASSOCLKMID MRM 'B"(s)TO TIIE IUUOWING ADDRFS&
<br /> SrAll.i OF CA1117ORNIA
<br /> SE IF,WNI'ER RESOURCES CON17ROL BOARD
<br /> C/o &Wnl�.Ps.
<br /> DATA PRRSSING ClIN111,'R
<br /> P.OBOX 527
<br /> PARAMOUNF, CA 90723
<br />
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