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NSM(ANItesls FOR C"0.`v4I1L1,'�J1NG FIRM "A'
<br /> WiNUMAL Il`I``a:F UMICDNN
<br /> 1, a:faa,, FDD.itti ?a shad! tic. conip�eccdl for all SIFIN PERMrPS, FERIeffI'CIIII t'1tei or sa„y ACllJ`l" fSVl'F
<br /> £ £{£,F FM-I Fly CFFNGI--S..
<br /> r € s 4Arirt a Aea regardfees of the t k;=,t,r,s.r of t-art?ts is c r;r.dt ah t;r. ,rr;.
<br /> , 1°:.,s tE.rr should bc. completed bv cither the 11f.l Mrl AIP11CANF air dic F,4)CzM, (;f?,N(,,Y t;N D1?1ltnit01-10)
<br /> 17,yap Il°uf.Pi*£.1 D)FF,
<br /> i'a � 6 ypc d a ;.ns, ck,,.aiiy ,,,iE )e tuef tc d infE3nn—mon,
<br /> ... Us e i. w'rc, i c,rpt as ting in Frau:an, You are making s copk,c
<br /> Mark an (p,) in free box next; t,o the it.c at that .Fa,scolies, tin, reason the f(irnt is brim, Completed,
<br /> " a
<br /> F, FaACetFi'DD'FIIFI I'C' ��
<br /> I A' £�' tD .S, taat,ySf"F3F;`CIDFIasIi`I1� "-
<br /> 1. Record waY;'r'e and aadFEtes��>"S.st,",�'F f o.>4ion r- of th"e Lit1derg"€`sund zcsnk(s),
<br /> 'gCiFl e Address $MUST` have a -valid ph sial location including c.ity, s¢atc,and zip code,
<br /> M TIOX NUMBERS ARE NMP ACX"FABLEL
<br /> Include nearest cress street, aml ca:zas of the €spennor._
<br /> S, Phone number bust, have at, area code, .ff ibc night nunitter° is 0,,c same, n,rite "SAN-TE" in pr€alrer location,
<br /> 1 Check the appropriate box fcr'I'YP W OF BUSINESS t WNI.' SI.111' ex, COlUIC7RM"ION, INDIVIDUAL, etc,)
<br /> -F, Check the appropriate box for'FYPE OF BUSINESS,
<br /> 5. If f"achity/Site is located within an Indian reasetvation or other Indian trust lands, check the hoax tivirked "YES".
<br /> Ci, Indicate the 'St;MBER ol''IA FS at this SJJ'f,,a;.
<br /> 7. Record.die .h;A. 11) rt or write "NONF" in rl,rc space; provided.
<br /> ,
<br /> FF. PROPEMY OWNER I 70 aS SFS (a ".7 F"BE L u IF)
<br /> Complete mplete all items in this section, unless all it?'rn, arc; the saarne as sI,CIION 1, if the same, write "SAM11 AS SI`f"Ii"
<br /> � .
<br /> tla,., section, Be cz° 1,ocfc. k I'ae€?a'F.Sy<D OWNERSHIP l3ttA,
<br /> 111. 'FAN £IWNIM INFORMNIMN & ADF.DRIIRS t 9C °sf IDS 1'IDSF�s FI I:D
<br /> a `M-,,a otc <aa, hello; in lir, sc-e;icm, un ss all it"mis so,, the ,.,a, as SF C.=F`1O.N 1 If the ;;untie urlf,., 'SAMEAS Srf'V acro;;:
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<br /> >., ., ..a.€,n- xct a,,.m Ro b...c:S °IAN'sv° CDIS,4I,M-SiRi f'S`PC.box,
<br /> IV, BOARD C"'FI F,CyI.'MIZ—A i 0of US`I'SF7FFA,0Fy 11,117,AT7C CDUN"I"NUMBER(MFIXFg E(-Q iILu,-1YII)
<br /> F'mer Board of p",cf.aHz t=cu" (1301,11 'U"31, soirage fee accountmunber which is required before,your permit appli(,,r§iota
<br /> can be processed, IFegist attire.;, vvit he pe.aE will ensure that you ill :receive a quarterly stonaggc fee return in reporting the
<br /> $0,006 (16 rni}ss) per gallon fee due, €n the number of gallons placed in yotar US"Ie, 'f'he BOF? will code l7t:s;conexempt fm,a
<br /> p ,% ag the storage Fee sea returns Ailf net be &ern. If you do not have an accountnumber with the BOE or if F{av have anv�
<br /> qo s?k)n: reFardira the feeo exemptions, please Orli tii, ROE at 916-323-9555 or write to the 101" ;at the foih`ivoraa¢
<br /> Board of Etivalization, I>a zr.e.=ltnacnia3 Fees Unit, F,O, Box .tat?879, Sacramento, CA 94-279-0 001.
<br /> V, ISI F I',IDF;t aUM UEF FaINANICIAL RESFDIDFsaSFi.3it i- (M IF'BE CCD= Is[' ED)
<br /> Identify the method(s) used b-v the ;surer and'or operate,- in meeting the Federal and State financial responsibility
<br /> ,muircnnertts, sUS'Fs clwnlol b'q arra Federal or S'taie agrency are exempt from this t.ecluirentenl.
<br /> ,. LEGAL -KY1111-U-NOONAND IFI..F,i &I ADDRESS
<br /> £.l,c k ONE BOX for the address that xa ill he ;,¢Feet for IFI9'I.l l U II I.<AND FFI F CI101711 C. "F"FCDN'S.
<br /> SIGN AND FDS"I'II'F7,M FORM ;sILII: ME),
<br /> I STYRUC"IF0 FOR'111113, L C T, 'D.CUCF aS
<br /> i>t„ coQnty >and j rhsdictfon nornN rs are prcricier,t,ned and can be obtained by calling the State Bard (916)739-2-42'1. "I'li
<br /> ? d6t{za,amber tray be a silgced by tabe local a„gcr,,gvy F`cnve er, this number must be n€3557e:['ical and cannot contain say,
<br /> al ..ibeli ad" If tile focal agency pr ycnt the state Utoard to assian the facUny number, please leave it blank.
<br /> 11 Iya`F F ,
<br /> RF-SMNS1BJT,rYY OF LOCAL A IIIFsK "'I t]Nf'INSPEX71N 111E FACIF,M, "M VERIFY'11114,
<br /> ACX,,'CJRA1,rw',Y OF'1711,',INIrCDRKNI10 f.. 1:111S t° PPIKA'171CDi'F C I"miN01'1311 PROCESSED IF 11111 FF Ci"I:DI1Nr
<br /> bR1,1013FI IS NMI' 111,11:ID IN, F"IFF:', I« (,,-,T, X,61I C;Y IS FBF:-SPON IBLE, 1AC)R 111E,t'CD;S PPE-1"I0N Ole mw
<br /> L DC,Al, Ia1l NCY USE' ONLY* INP(MMMION BOX AND FOR.I;(FICWtCIIDING ONE. FORM "A"AND
<br /> Mosk)(''F x11,11) F€.MI' '"at as F°I°F::t '111F FaCDF,F.y MING Al"DFDIF.ENS,
<br /> S"I's" VISI OF C F.Ih"ORPO
<br /> sxl'
<br /> F aD SW. a p;SC.
<br /> DK[ot I"FI C aSSIN z
<br /> p,O.. BOX 527
<br /> p `Us10 `.-, S 9075.
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