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<br /> 1. One FORM'A" be comps cmd for all NfV PI?RMPJK, "(3IAt(HS or anyFAClimy/snIH
<br /> 2. switma ONLY ONE(1)FX)RM /1.*for a Fac ity/Site, regardless of the number of tanks located at the'saite.
<br /> 3. This form should (ac completed by either the IT'.1C;yhr PLICANF car the L O( L 4 lWC'Y LJN13I?tLekbUNi TANK
<br /> 4. Please qTe or print clearly all requested information,
<br /> 5; Use a turd point wrifing instrument,you are making 3 aspics. '
<br /> n
<br /> TOP OF HDRM. 'MARK ONLY OW TITM*
<br /> x ,. : �
<br /> 1. Mark.an iX)tr the box next to the item tf�t best describes the reason the forms is being completed,
<br /> T. La C.`011 ' a 1F; 1 1�I`O t I3TW S° L)>1'13fA£,"CD T"i 1;1 1 ) w"
<br /> ].
<br /> R crord rsame and address(,physical location)of the underground tank(s).
<br /> Address MUS`? leave a Tali physicrat location including city,state,and zip code,
<br /> Include nearesi crass street<a.nd name of the operator.
<br /> 2. Phone number rrarst have an arca code. If the night number is the same,write "SAME`it,, proper location.
<br /> 3. ('heck tfte<_„appropriate,bslx for'IYIIE OF 1iL;rtiINF',SS OW 1316111P(ex, CORPUd2.,�'110N, INDIVIDUAL,`,cic)
<br /> 4'.” (,beck if c apfssxsl,riFate't ox for TY E, 0I-BUSINESS.
<br /> 5, If Facifity/`be is located on,laird within an indian reservation or other,Indian trust lands,check the box marked'YES',
<br /> S".
<br /> ti. Indicate the NUN-s`FIF.IR of T',aNXS at this SI EL
<br /> Record the I. Tr A, 11) or write 'NONE"in the space provided.
<br /> 1. ("ranplete all items taa4. c tion, a,ftie alb lt£rra are the same as S17,CTION 1;;if the serine write L;. S fll,!*across
<br /> t4aas scaa 1 . <alre to eftnc EI i;kh' OWN-rasillp �' 'T„I>ax.
<br /> Ill.TAINK OWNER INFORNIN11ON&ADDRE&S( 'US—lf 11F C'oMPLIU111))
<br /> 1. „Complete all iterns in this section, utsl€.ss all items are the sarne as SEC)ION l; If the same,write'SAME AS Sr I?'
<br /> across this section. .Be sure to cliecA`1 . K.OWNERSHIPTYPE bore:.,
<br /> IV 19)ARD OF UAIJ7 '100 US°1'91'ORA(11?HS!? £: LJNTF BlT d.9r 311?C() H:1CIVID
<br /> Enter your Board of Equalization(BOF,) USI'slorale,fce account number which is required before your permit application can
<br /> be pees%essed. . ze,yis ratior:,with'tse 1101i will ensure.that you will receive a quarterly storage feta ret=.arcs in rcaptlt•€arrg me ko
<br /> (6 rn'slls)per gallons fee due on the spaimber of gallons placed in your USTs. The OE"will aside persons exempt from paying the
<br /> storage fee ser returns will not be scnt. if you do not have an account number with the BOF or if you have any questions
<br /> regarding the I"ec or excl ptions,falc:ase call the 1:31213 at 916-739-2582 or write to the WE at the fc dowing address: Board of
<br /> El"Clualization, E vironmental lees Unit,T'.£1, Rox 942879,,aSacrsament<), CA 94279-(I()t)l;
<br /> L Check CNH BOX for the address that will be usedfor I3( ITT LWAL AND 14111.,T C1 N( 111h "t`C3. .e.
<br /> AM La Tia JSr,S1C I'1 I JVI1i.'l l 1 L AS T . 1(�il'1'.12.
<br /> `lice county,and jurisdiction members are predeterminedand can be obtained by calling tkih State"Board (915)739-2,421." f he
<br /> nicilitg number may be assigned by the local agency, however,This number must he numerical and cannot contain an alphabet. If
<br /> the local agentT Prefers the State.Board to assure the facility number,please leave it clank
<br /> Cl`v;,nuz R1 SPON 11TH,<I":T`Y OF-111T1,LOCAL AGIINCY111AT 1 SPBf,-L"1i'I1[I[i FACM11N"T OV1!12T1 "11 w,
<br /> A(C"U1t. C`Y€ F 311117 1NIr£RWV11£t:N. "$1115 APPLICA110N£`:A £3'T'1? a PROCA�i.`�ED IF71113 111?BOH A(',£'C)t, :"1"
<br /> LUMBER IS td£71 x111.11.)Ili. 'l it?l( I:. C1is ( 1S 02I?�PON%I111 ?tl(.)R lllli C OMVI,?17 3 1)17°1"1101*I 1C. n
<br /> GI C:' 'US11 ONLY"Y"INFOR rt'I"00N BOX AND FOR F(WWARDING C2 la FORM W AND AW)CIA7110 FORM
<br /> -(s)-170 I IE F0,1112 INNDDR VS.
<br /> . �
<br /> DVIT WNI AR fS30 11CC1!.%COMpRal,13:BOARD>
<br /> P.O( BOX 52-
<br /> RAMO a111',CA W723
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