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T-7 s a. -5, IN'S'IRUCIIONS FOR COMPLETING 17ORM W GENERAL 1N5.I'RUC11ONS: 1, One FORM "A" shall be completed for all NEV PERNIM, PERMIT CITANGE-S or any VACII.rvy/srns INFORMX110N CI-IANGRS. 2, suBmn, ONLY ONE (1) FORM *A" for a Faqility/Sitc, rcgardloss of the number of tanks kwated at i hr silc, This form should be completed by either the PERMIT APPLICANT or thc LOCAL AGEINCY 1J'NDI�RGROt,ND TANK INSPEC'FOR. 4, Please type pe or print clearly all requested information. 5. Use a hard point Writing instrument, you are making 3 copies.: "11OP OF FORM: "MARK ONLY ONE ITEM" Mark an (X) in the box next to the item that best describes the reason the form is being completed. L FACILYI-Y/SnE, INF1ORMA7nON be ADDRESS (MUST BE COMPIMrD) 1, Record name and address (physical location) of the underground tank(s). NOTE: Address MUS"' have a valid physical location including city, state, and zip code, P.O. BOX NUMBERS ARE NOT'A(X1--Jr1'AB1J-'- Include nearest cross street and name of the operator. 2, Phone number must have an area code. If the night number is the same, write "SAME" in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNTFRSIIIP (ex. CORPORATION, IN[NVIINJAL, etc.) 4, Check the appropriate box for'TYPE 014' BUSINESS. .5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YLS'". 6. Indicate the NUMBER of TANKS at this SITE-. 7. Record the E.P.A. ID # or write "NONE" in the space provided. H. PROPERTY OWNER INFORMNIION&ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as S17CI'ION 1; if the same, write *SAME'AS SfIV7 across this section. Be sure to check PROPERTY OWNERSHIP TYPE box, Ill. TANK OWNER INFORMATION &ADDRESS (MUST'BE COMPIM-11313) Complete all items in this section, unless all items are the same as SECTION 1: If the same, write "SAME. AS S11VI" across this section. Be sure to check TANK OVINEILSUIP'IYPF box. IV. BOARD OF EQUMIM17ON UST SIX)RACY11 FEE ACCOUNT NUMBER (Mus-r BE complix.n.,D) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting- the $0,006 (6 mills) per gallon fee due on the number of gallons placed in your USI's. The BOE will code PCt-soins exempt from paying the stcrragY6 fee so returns will not be sent. If you do not have an account nu ber with the 140E orif you havc.any questions regarding the fee or exemptions, please call the BOE at 91.6-323-9555 or write to the BOF at the fallowing address: Board of Equalization, Environmental Fees Unit, P.O, Box 942879, Sacramento, CA 94279-0001. V. PETROLLEU M U917 HNANCIAL.-RESPONSIBUnT (MUST BE COMPLU FF.D) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. U91's owned by any Federal or State agency are exempt from this requirement. V1. IXIGAL NO(Fl[FICATION AND B1111NG ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND B111ING NO'1111(WI]ONS. APPLICANT M13gr SIGN AND DA3V 'nIE FORM AS INDICATED. lN51RUCnON FOR 114E LOCAL AGIW(1[0S the county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number may be assigned by the local agency. however, this number must be numerical and cannot contain any alphabeticaL If the local agency prefers the State Board to assign the facility number, please leave it blank. rF IS'ITHI RESMNSIBU.M OF171EF LOCAL AGENCY ITIAT INSPECTS Inl[E FACILITY TO VEW27Y 111111i A(X,'URACY OF'IIIE INFORMA71.10N. THIS APPLICATION CANNOrr BE PROCE-SSED IF"IF,1130F ACCOUN71' NUMBER IS NOT 1-111,Fl) IN. TTW-, LOCAL AGINCY IS RESPONS1111)[11 FOR TIIE.COMPLETION OF TIH! *IA XAL AGENCY USE, ONLY* INFORMA11ON BOX AND FOR FORWARDING ONE FORM '.A'AND ASSOCIA717ED FORM W(s)TO 11IF" FOLTAWTNG ADDRESS. STATE OF CAHFORNIA 917A717F WAFER RESOURCES CY)WROT. BOARD C/o "miuLps. DATA PROCHSSING (I.,2M--R P.O. BOX 527 PARAMOUNT, CA 90723