|
IN51110ANIONS Ts('-)R COMPLFIDNCI 11Y)II'M 'A'
<br /> GENERAL INS-JI'RU("'I'1()N-,1,3,
<br /> "Olym sih.-fl. N'. ior ill Nl,,NV FACIISt"Y"I'l-TIT"
<br /> 1NIFORMA170N CHANGF11,13,,
<br /> R a
<br /> SUJOAU' ONIN' ONH (1) F(MRl,"A", "PO for "- I
<br /> 11"is form sh"ould ti'c by efflier 'he PECNIFF or Ih,,:' AUENCY UNYWIZGR'(=2,- 1,
<br /> IANK INSPF('I'0R.
<br /> -f"' 1, -ino cl�, --qwc�
<br /> 4, Plea-, ypt' "m p; ark, �ffl sted informadc'n
<br /> Use a lh,rd pw,,ina writi". -ou are n1aki"n" 'i
<br /> p K'11'
<br /> '1`OP OF ,!AE K ONLY ()N-t" l'I "
<br /> an (X'i in uIe I"ev to liv, rt war fl"M hem cicsr-J)C- -ens a. flic b
<br /> 1NF9J&MYV,'1`T0N ,&, ADI)RnkS (MUS1BE
<br /> 1, Record Panic iiocl atail rte;s (physical loclion) of the vndcrgrc�und
<br /> NCI'I'FAddres's NIUSI' have is valid physical fivation inciuding", dly, 'Iale and ccaic-
<br /> P0, BOX NUMBEWS ARF N(Yr A(,('WqAllfli�
<br /> Include nearest, crca,,,,s street and name of tire openator,
<br /> 2, Phone numust ust have an area code. If the night number js"H)c Sane, wrilc `SAMF�" in p�npor loc"Ifion,
<br /> 1 Greck The appropriate b6X fi.)r ']'YPE OF' BUSINI, S OWNFICS11111 (<,,x. C0RP0FA'Y1(-)N, INDWI6;)1 ALcic-)
<br /> 4. C"beck the appropriate box for 'FYPEI OF BUSINF,`S.
<br /> 5. If Facility/Site is located within an Indian reseivation or other Indian trust lands, check the box marked "YFIS",
<br /> & Indicate the NUMBF'R ol' 'IANKS at this srn',."
<br /> 7. Record the EXA, 11) # or write "NON13" in the space provided,
<br /> IT, PROTIEWILY OWNER INMRMNIION & AI DRI.3-ss- (MU,,;[ 13F C9 MPIJI1171))
<br /> Complete ,ill items in this section, unless all items are the same as Sl,'(,,'I'ION' 1; if tbc, sarne, w'rhe 'SAN4F AS SrFF
<br /> this section. De sure to check PROPFIKI'Y OWN11,1611111 'rym'," ilox,
<br /> 1IL TANK OWNER INFX)RMNITON & ADDRE&S wusr Tu.7 cowurxwi)
<br /> Complete all itenis in this section, unless all items are the satoe as SE(NION 1; U Inc sanic, write ",15AME, AS S117"' =WTO '
<br /> this section. Be sure to check 'I'ANK OWNEWSIH11'17YPE. box.
<br /> TV. BOARD OF EQUALIZA11ON LTS'F,16;1'ORAGE 1 �'F.ACCOUNT'NUMBEIt (MUSI"1111 COMP11FIE.11)
<br /> Inter your Board of Fklualization (BOE) U5.1' storage fee account numbei,which isrcquired before your PC1111fl application
<br /> can be processed, Registration with the B()13 will ensure that you will receive a quarterly slora"c fee return in reporling the
<br /> S0.006 (6 mills) per gaflon fee due on the number of gallons placed in you, US'I's, I'lic BOE will code persons cxcinpt from,
<br /> paying the storage fee so returns will not be sent, If you do not have an account number with the BOF fir if lou aIny
<br /> questions regarding the, fee or exemptions, please call the BOF,at 916-323-19555 or wi,ice lo tile 80F, at the follow�m'
<br /> Board of 1"'qualizalion, Fee's Unit, 11'0Box 94-1879, Saorcmenlo, CA 94279-000L
<br /> V. PE'FROLEUM L1,51'FINANCIAL RENPONSIBU,171"Y (MIJS-r BE COMP11,111,3)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements, U,S'I's ow ed by any Federal or State aggenry are exempt frorn this, requirement,
<br /> VL LF',GAL .N(Y]11q(.WJ'J0N AND 3LhL CIADDRIT-15S
<br /> Check ONF� 13OX for the address that vill lie tried for B01D LEGAL AND 13111ING N(Y1TF(CNJT0NS.
<br /> APP11CANIP MUS'I'SIGN AND DMI M'17111, 17ORM AS 1NDI(,WT1:1D,
<br /> 114517RU(TDON FOR 111E LOCALAGENCIES
<br /> 'File counry a Fa risdiction nut bars are predelerre"red and can be c'b'alncd !"V call ing the State Board (916)719-2421.
<br /> facility` number,Inay be assigned by ific local ag'CrIcy' bowevc—, thi -,nn
<br /> �, mwbe� uws� �e namicTicil and cinnot contain anv
<br /> alphaiv�ticaL lfihe localP
<br /> agcncy 'refers, the State 'hoard Co' 0-11c numctr' plase leave it blank,
<br /> rr IS'111E RES POISSIB11IFY OF'1111 LOCAL AGENCY '111AY INSPINA'S'FUE FAC IIII'N 'I'0 VERIFY 'DIE
<br /> A(X'URA('Y Ir DIF INFORM/01ON, IIIIS APPLICA'17ION CANN(YJtil, 1'R0 `P',SS1-'1D Fir'11IE 1301,"A(XX)1JN11'
<br /> NUMBER IS N(Y1' 1,111,M) IN. '111F LOCAL ACI Igq(,—Y IS RRSPONSIBLIJ" 14CIR'nw, COMPLEHON OF17111i
<br /> 'LOCAL AGENCY USE.ONLY' INFORMNI'TON BOX AND FOR FORWARDING ON1 FORM ',t\,' AND
<br /> A&SOCINIF,J-) FORM 1p`(s)-10 -111E' F011,0WING ADDRFNS,
<br /> SFNIU OF CALIFORNIA
<br /> 1TI'JVFE WNI'ER R[SC COWROL WARD
<br /> DAA PROM SING CISS7114,1k
<br /> P'Cr BOX 527
<br /> PARAMOUN717, CA 90723
<br />
|