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INSTRUCTIONS FOR COMPLETING FORM "A" IN.517 kX-HON'S. 1. One FORM "A" shall be completed for all NEW PLERMTPS; PERMrr CIIAhIGES or any FACIITI'Y/Srl'I3 INFORMATION CHANGES 2. SUBMIT ONLY O (1) 17ORM "A" for a Facility/Site; regardless of the number of tanks located at the site. 3. 'I'his form should be completed by either the PERMIT APPLICANT or the LOCAL'ACsENCY ElNI)FIR iROI.NII TANK INSPI C'rOR- �``__ se type or print clearly all requested information. U,;c a hard point writing instrument, you are making 3 copies. `IOP 0, "MARK ONLY ONE ITEM" ..:k_ an (X) in the box next to the item that best describes the reason the'forret is being completed. L FA(-I rrY/,SrrF 7110 ADD (MUST BE CO14IPULr ED) 1. �Record namc and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city,state, and zip code: P.O. BOX NUMBERS ARE NOT ACX. Include nearest cross street and startle 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 OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indicate the NUMBER of TA:NIC,S at this SITE. 7. Record the E.P.A. ID # or wr#e "NONE" in the space provided. PROPERTY OWNER INFORMATION&.AICD 7 BE D) Complete all items in this section, unless all items are the same as SECTION 1; if the same,write ": E'A.S SITE" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. TANK OWNER INFORMATION&ADDRESS ( tuS'r mD Complete all items in this section, unless all items are the same as SECTION 1; If the same, write'"SAME AS Srrl" across this section. Be sure to check T OWNERSHIP TYPE box. IV! BOARD OF 1 QUAI YATION UST RAOE FEE ACCOUNT NUMBER(MUST BE COMPLETED) 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 UM. The BOE will code persons exempt from paying the storage fee so returns will not be sent;'If you do not have an account number with the BOB or if you'have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or,write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O.Box 942879, Sacramento,S A 94279-0003,. V. PUPROLEUM U FINANCIAL RESPONSIBILITY:(MUST BE COMPLETED) ' Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs owned by any Federal or State agency are exempt from this requirement. LEGAL NOTIFICATION AND B111ING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE`11IE FORM AS INDICATED INSTRUC`FION FOR THE LOCAL AGENCEIN 1 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. IT IS ITIE RESIONSIEBILITYOF'111E LOCAL AGT INSPECTIS THE FACILITY TO VERIFY TM ACCURACY OF THE INFORMATION. THIS PLICATION CANNOT BE PROCESSED IF TME BOB ACCOUNP NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE COMPLETION ON OF TIIE LOCAL ,, AGEN usw.oNur iwoRmAnm Box AND FOR TORWARDING O "Aa AND ASSOCIXPED FORM "B"(s)TO THE FOLLOWING ADDRESS. STATEOF CLIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O .IS . Sm DATA PROCESSING CFNrER P.O. BOX 527 PARAMOUNT, 3 E