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IN-KI'RUC11ONS II)R COMPIX-11#)RM -A- GENERAL INS71RUCHONS- 0 1. One FORM "A" shalt be completed for all NEW PERMrtS, PERMIT' 01ANGF-S or any FACTIJI-y/srui. INFORMA11ON CIIANGII-S. 2. SIJIIMrl* ONLY ONE (1) FORM *A* for a Facility/Site, regardless of the number of tanks located at the site,. 1 This form should be completed by either the PERmrl`AI`PIJCANr or the LOCAL AGENCY UNDERGROUND TANK INSPIXXOR- 4, Please type or print clearly all requested information. S. Use a hard point writing instrument, you are making 3 copies. TOP OF II)RM- 'MARK ONLY ONE rrFW 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed, 1. FACILI'l-YIS11711. INFORMATION & ADDRI.I&S (MUST BE COMPI1rl1iD) L Record name and address (physical location) of the underground tank(s). N01T: Address MUST have a valid physical location including city, state, and zip code. P.O. 13OX NUMBER ARE NCfFACC17rA11I1! Include nearest cross street and name of the operator. 1 Phone number must have an area code. If the night number is the same, write "SAME" in proper location, 3. Check the appropriate box forTYPE OF BUSINFSS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) 4. Check the appropriate box fbr'I"YPE OF BUSINESS. 5, If Facility/Sits is located c)n land within an Indian reservation or other indian trust lands, check- the box marked "Yl.' -s". 6. Indicate the NUMBER of 'TANKS at this SITE. 7. Record the E.P.A. 11) # or write 'NONE" in the space provided. IL PROPERlY OWNER INI?ORMKIION & ADDRESS (MUST BF COMPIX-110) 1. Complete all items inthis section, unless all items are the same as SECHON I; if the same, write "sAwi AS srn.i* across this section. Be sure to check PROPERTY OWNERS11111TYPE box. 111. TANK OWNER INFORMXIION & ADDRESS (MIJSF BE COMPIX-111D) 1, Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME ASSrI13' across this section. Be sure to check TANK OWNERSHIP TYPE box. IV BOARD OF EQUALIZA11ON UST S1`ORA(;E Flat AccOumr NUMBER (musr BE compumif)) 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 $0006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOF 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 BOF, or if you have any questions regarding the fee or exemptions, please call the 1301, 'at 916-739-2,582 or write to the BOE at the following address: Board of Iklualization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. 11XIAL NO`I1FTCNI1ON AND 1311LING ADDRE&S I. Check ONII BOX for the address that will be used for B(MI LEGAL AND BH.IING NO`11IqCNI1ONS. APPLICAN'r MUST'SIGNAND D/VI`E'11IE FOFM AS INDICA11M. INSTRUCITON FOR TSE IMAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2427. The facility number may be assigned by the local age-,cy, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to the facility number, please leave it blank. rF LS11113. RESPONSIBUXI-Y Of' "IE LOCA AGENCY IIIATINSPFCIS'llil:!FACItXIY'I'OVtiRlIlYlTili ACCURACY OF77IF INFORMXIION. 11IIS APP11CA71ION CANN(Yr BE PROCI-ISS111) IF771F. BOE ACCOUN17 NUMBER isN(yrm.LE,,DIN_ n Ili mcm, AGENCY IS RKSPONStBIT, FOR 1I IE COMPIVIION OF 1*1 IE *LOCAL AGENCY USE ONLY" INFORMA711ON IX)X AND FOR FORWARDING ONE FORM *A* ANDASSOCIA`IED FORM W(s) -1-0 IIIE FOILOWING ADDRESS. SE)VIE OF CAIIFORNIA SrXIF. WJVI1iR R13SOURCES ())N7VROL BOARD C/O S.W.IiF-P.S. DATA PROCESSING CT: NILTR P.O. BOX 527 PARAMOUNT, CA W77-3