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<br /> flN:'xFH1A.a a VO (.t' I11,1 FORM OAS
<br /> GENFRAI, h c,.I2Cl ,q
<br /> „gpleted for all dlpW ERWI g PI?.IZI�IY['01f4.ly GES or any F AC'FI.CIY/,STTV
<br /> S1.11ho 1 ONF II1I�I 'A" for a i acili?:y;'Sitc, regardless of thenumber of tanks i��zaEc°d sit r(t;: S1101
<br /> This t....as ,.Find b(,, completed by either the PI 'KNIT[ 1kPP11hN or the LOCAL AGENCY LlNiyl;Ct<IIZt3Ulal)
<br /> '(1S,aK INSPEC7,A)R.
<br /> ; Re,,we type or p.ria, cle,:ril° «l mquested information,
<br /> W r iong-ire„tra:a r t, you are making 3 copies.
<br /> wth 1,
<br /> rsc a. ,,a i. h;.ax<-next ua (Ise tern that Gess t cribes Ilse reason elle fast err is[?a ztsg'tons Eeke i.
<br /> Bec)RAvvilioN& !iF'2DR ( u sr BE COMPLETED)
<br /> ', Record same and address (physical location) of the underground tank(s).
<br /> Os1° E"v2�sress xle. 'have a valid physical-location including city, state, and zip code:
<br /> I>nclude nearest cross street and name of the operator.
<br /> 2, I='.... Asa;assver must have an area code, If the night number is the sante, write "SAME" in proper location.
<br /> 3, Clack the appropriate box for I PL. OF BUSINESS SS OW'sxER SHIP (ex. COPC.)R/V PION, INDIVIDUAL,, etc,)
<br /> ,I Chea ck the approo-prate- box for TYPE 01`'BUSINESS,
<br /> 2, If Iracility,`Site is located within an Indian :reser tion or other Indian trust lands, check the box marked "YE's”,
<br /> f;, Indicate the NUMBER of TANKS at this SI'I`I:>.
<br /> Record the E.P.A. 11) # or write "NONE' in the space providbd,
<br /> H. PROPF'.11<1Y OWNER INFORMNnON&tli)'I RE&S ( IJEr B () l tfi Q) � t
<br /> d
<br /> Complete all items in this section, unless all items are the same as SC;C:riONr 1, if the same., write ".'SAMI S ISFI'tt" ,re r'cs44
<br /> this section, Be snare to cock PROP1`sl2r Y OWNERSHIP TYPE box.
<br /> FII_ TANK OWNER INFO MA1,10,14 & , DDRE;?-&S (INCISE'BE C I.,I 11-1)) x
<br /> s ,
<br /> C'ornplcte all items in this section, awnless all items are the sante as S C"1'I N 1, If the saner,wr°ite "r"SAME 4F,1"F :acrtc")r,s
<br /> this section, Be scare to check:TAN �? IP 7 P hon. � r„.m
<br /> IV— a I AI2t” . P QUALr/NF"1C3I .l SIO °(FI?F E, C COuN°NUMBER UI;-r BE F'IH3,Y-0
<br /> Enter your Board of Equalization (B011) UST storage fee account number which is required before your permit applicancsrr
<br /> can be processed, Registration with the BOE will ensure that you will receive a quanterty storage: fee; return in reporting the
<br /> $0006 ((i mills) per gallon fees due on the number of gallons placed in four I" 'J's. 7"Ife,11C)IL will carie persons exempt from
<br /> paying the stcsrage fee so returns will not he sent. If you do not have an~atd� f sttntGd� or if you have arsy
<br /> suiestio'ns regarding the:, fee or exemptions, please call the BOE at 916-123- 555 or write to the BOF at lbe following ,acl<1ress<
<br /> board of Enivalization, Caw mrnental Fees Unit, P=0. Box 942579, Sacramento, CA 94279.0001,
<br /> v. Prr,rRo-i.,i:-,,uSiusr n,NAS CIAL RESPONSHIR11Y(WJSr BE COMPLI-r][70)
<br /> Identify the method(s) aascd by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirement-, 91's owned by any Federal or striae agency are exempt front this requirement.
<br /> I. LEGAL N(YI'114CNFION AND 1111LING ADDRE&S
<br /> Check ONE BOX for the address that; will be used for B(Y11-I 1-1X3AL AND I3 Ca T (Y1111IC.HONE.
<br /> APPI CLAW ICrSP SIGN AND NIM THE FORM AS I ° 110.
<br /> INS'AUCITON I=tJIC THE LOCAL AGENCIES
<br /> IES
<br /> The county and jurisdiction number; are predetermined and can be obtained by calling the"Mate Board (916)739-2421. The
<br /> facility ntntiber may be Eassif;nc+ by the: local agency. however, this number must he numerical and cannot contain any
<br /> alphabetical, If the local agency prefers the State board to assign tile:-facility number, please leaveit blank. -
<br /> I"1'IS T111i RESPONSMILT]'Y OF 11113T? LOCAL AGENCY 17TAT INSPEffS 111E FTA y C`'10I' ice'ITHI
<br /> A(X'UR . 'O 1:11:. INFORMA11ON, TIHS PPIJ(WnON CANN(Y I EIBEflR0CE-&SEb IF nIE BOU .0 ` NI"
<br /> a. U IS C p F �ED 14" TIE e ( I� I . I< . R.SPONSt i r PI,I-;, ;0F' T i
<br /> a x �
<br /> .. "F..2( I�AGENCY Y UIIE 8m',' li k5 .'rJ0N W FOR I I� RDING,O ICD, "A"AND
<br /> ASSOCIN1.10 FOR "II'(s)TO THE 1 a)tWV?ON(`; I:DI ICI3�v5. s
<br /> SFAIT,W,€ I : , RE-SOURCES ( .) 0L..BOARD
<br /> �gf 5. 2I s
<br /> P :MC1 ' CA 90723
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