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INSI"RU('17TONS A)R (.£)h2i'I..1:"1"LNG FORM W
<br /> GENERAL TNS'f'RUCTIONS.
<br /> 1, One FORM "A" shall be completed for all NEW PERMIllS, I'ERMrI'CHANGES or any 1aACIi.WY fSITE,
<br /> INVORMXF1ON CHANGES. \.
<br /> 2, SUI;Mrf ONLY ONE (1) FORM "A' for a Facility site, regardless of the number of tanks located ai,tb� site.
<br /> 3. This forts; should be completed by either the PER'yIIT APVLICANI'or the LOCAL AGENCY UNI3FR,(�Ro l Nt)
<br /> TANK INSPI"'OR.
<br /> Please type or print clearly all requested information.
<br /> lase a hard point writing instrument, you are making 3 copies.
<br /> '['OR OF FOR 'MARS; ONLY ONE ITEM'
<br /> riark an (2s) in the bo- ;~-xt to the item that best describes the reason the form is being completed
<br /> D' R11—ss (MUST BE (:iW IX;'11?.Dj
<br /> 1.., Record name and address (physical location) of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX N ERi ARE NOT A' lAI11T
<br /> Include nearest cross street and name of the operator.
<br /> 1 Phone number must Pave an area code. If the night number is the sante, write "SAME" in proper location,
<br /> 3. Check the appropriate box fax TYPE OF BUSINESS OWNERSHIP (ex. CORI1ORA'I1ON, INDIVIDUAL, ctc.)
<br /> 4. Check the appropriate'-box for TYPE OF BUSINESS.
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust lands; check the box marked "YE-S".
<br /> 6. Indicate the NUMBER of TANKS at this SITEL
<br /> 7, Record the 'ETA. 11) # or %.tire "NONE" in the space provided.
<br /> I.I. PROPEWFY OWNER V0k)RrAA11ON &ADDRESS (MUST BE COMI'LEIT l))
<br /> C',omplete, all items in this section, unless all items are the same as ,SEOFION 1: if the same, write "SAME AS SHE ica-oss
<br /> this sccficm. :l:e sure to check PROPFwiY OWNERSHIP 71YPE box.
<br /> III. TANK OWNER IWORNINHON & ADDRI?SS (MUSI'BE _ " 1)
<br /> Complete all items its this section, unless all items are the same as SEC'FIONr 1; If the same, write "SAMP AS ;SITE acro."
<br /> this st.ction, Be sure to check TANK OWNER-SHIP TYPE box.
<br /> IV. BOARD OF Es UAI.17`,KITON USl'1vTORAGI3 141?I?ACCOUNT'NUMDER(MUST B13 COMPTJ. ITT7)
<br /> ater your Board of Equalization (BOE) UST storage fee account number which is required before your permit application
<br /> san be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting; the
<br /> %006 (6 mills) per ballon fee due on the number of gallons placed in your U:S'Ts. The BOE will code persons exemp} from
<br /> paying the storage fee so returns will not be sent. if you do not have tm account number with the 13OF or if you h.tvc any
<br /> questions regarding the fee or exemptions, please call the 1303E at 916-323-9555 or write to the BOL: at the followin addles:
<br /> Board of Equalization, Environmental Dees Unit, P.O. Box 9.92879, Sacramento, CA 94279-0001,
<br /> V. PErIMOI.EU:Nf I.JS-r FINAIWIAI, RESPONS113111Y.Y. (MU . BE COMPLIs`TED)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any Foderal or State agency are exempt from this requirement.
<br /> VL IJIGAL N(YI1I1C',ATION AND i 1.I.tNG ADDRI
<br /> Check ONE BOY for the address that will be used for BOHI IJ3GAL AND l IIJING NC 1 (A"'RONS.
<br /> APPLIC:AW MU.' ' SH114 ANT) DA'F'1111i.fk)RM AS I(Wfl .
<br /> INS•I"RUCTION FOR THE LOCAL AGENC TES
<br /> The coumy and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The
<br /> facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any
<br /> alphazbet=cal. If the Local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> F'1'IS IIIL% S1I3II 1'Y OR niE LOCAL AGENCY TIIA°I'1NSPE.0 I`S'111E FACILITY TO VI"RWY THE
<br /> ACCURACY OIC TIII=,INFORMNIION. 'ITII S APPLICA'11ON CANNOT BE fl ROCS SFD Ila TIJE ROI:ACCOUNT'
<br /> UfWWR IS N(YC 111,1,13) IN. "I IF"s L(WAL A(;Iq%J('Y IS RIISPON sII3LE FOR'DW COMPIX-HON OF'I11E,
<br /> 'LOC/U, AG NUY USE' C ENL Y' I FO A 1`It N JX)X ANIS FOR FORWARDING ONE 1"RM "A"AND
<br /> AS,SOCIA'I' D FORM "B s) TO a IIE t'C3L,1,€)WING A[)I.11 RSR,
<br /> S t'AITs OF CALIFORNIA
<br /> NTA'17E WATER R°SOURC.ES COMI'CIL BOARD
<br /> CEO SS.Wx I?P.,&
<br /> DNIA PROCIISSING t NITiR
<br /> P.O. 13OX 527
<br /> PARAMOUMr, CA 90723
<br />
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