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I FI UC 17ONS POR C,a,1`KTPLFTING ?
<br /> . ., s ,,,
<br /> ,i s , , € lar ail NEW 1 Ii,; ' , "`C:TttfTEN or any I= {`[.I` Y°J4rI
<br /> 2, ~�`UBMI " N'1. ONE I) �^ � 7 l%vr a Facility/Site, s��,�zckt���� z f the number of tanks 3�x�tcd at the ,etc..
<br /> 1. s e. .rr s'hind be €°olnrieled by coba,,, tine PER1t1i'1`.?�E'E�LIf"7h J'or the T.t)C:r L GE Y CJl`v1)l R(;Rf31.Nl:)
<br /> TANK foSPEC]'OR.
<br /> pr;%n l,-rl all reclueste l information.
<br /> " ,�rd 1...art;*,o, it, instrument, yen are making 3 copies.
<br /> ONLY ONE, FJT'Ivl'
<br /> p an (X) in the bcx nnut to, ttaC ,ten_ 'hajvst describes the reason the form is being cerastpleteci.
<br /> f F"'il t"..,I`Y` ST"I`1f.' O R A-1Tt1 F& ADDR11-SS, (MI;1- BE('.(d PLE-T'E:xt3)
<br /> I. Record name and address ((physical 3€acri ,,3
<br /> on) of the undergro tank-(s).
<br /> Nt>FF: Address MUST have €a va d ,}!;;tical location inclu e ;city, state, and zip code,Taw . CI NUMBERS ER I.AR � "I°. � FABL,L?
<br /> Include nearest cross sheet aat name of the operator,
<br /> 2, Phone number must have an area code, If the might number is the same, write `,,3AM?" in proper lucaticyra.
<br /> 3, Check tire appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. (-,'0RI'()RAfION, IWIi IDIL,"A .. etc,)
<br /> d. Check the appropriate box for°hy,F.rF< OF BUSINESS.
<br /> u If Facility/;'rite is located within ail Indian reservation or other Indian trust lands, ciseck the box marked YFS`.
<br /> 6, Indicate the NUMBER of°t`AN S at this SITE',
<br /> f, Record the E,P.4. 11) # or write "NONE' in the space provided.
<br /> 11. PROPEWlY OWNER I IX)Tt 7111. Eyi)ROSS ( . til' BE(X) 11'1 FI1lD) ,
<br /> Complete all items in this section, unless all items are the carne as SEC '1; if the Santa:, write 'SAMP ds AS SrW across
<br /> tl,:s section, Be sure to check PRC)I'l^',ICrY OWNERSHIP TYPE box.
<br /> IIF. TANK OWNS't INFORM/010N & ADDRRSS ( €jSTBE:3 C:oMPI I'l ))
<br /> complete all items iat this section, unless all items are the same as SEC,'rION );,If that sante, write 'SAME AS smi. ,vats,,
<br /> dais section, Be sure to check TANK OWNFRSHIPrYPEbox.
<br /> IV, BOARD OF WILIA117AITONU9 S'FOR.a GE FEE', .C.C:C?tJI' I-NUMBER ( uw BF C>C) '€*Irma))
<br /> neer your Board of I feta.,Haien (Bol`") UST storage fee account number which is required before your pea-nrit dpplict.tivar _
<br /> Last, be processed, Registra8aon with the BOH will ensure that you will receive a quarterly storage fee s-eturn in reflorra the
<br /> $0,006 (6 mills) per gallon feet, dine cats the number of gallons placed ill your US`s. The BOE will code persons exonsPr from
<br /> pa% ng the storage fee so rctu°ns r is not be sent. If you €o not have in account number with the BOF or if you have any
<br /> clue suons, regarding the: fee or exemptions, please call the BOE at 916-323-9555 or write to the 130F, at the following,
<br /> Board sof Equalization, 1-,nvirt)S"xmcn1Pt Fees Unit, P'0,,Box 9142879, Sacramento, CA 91I2179-0001.
<br /> l lcmif Y the aat0hod(s) used by the owner and/or operator in meeting the:Federal and State financial respon'W,ifitk
<br /> ieputrements. US`F,; owned by arty Federal or state a�n ncv art,, exempt from this requirement.
<br /> VI F.T:<"K AE.,NXTITHC'KnON AND BEET E CI t Dtrllat S
<br /> Check ONE K)X for the address titan, will be used for I3GH1'LfXxAl,AN13 B11 C1 N01'Hw,wi1on&
<br /> AIx ,I£„.A?VI' I4 U,`TF S[GN AND Id. "1 1111 TIORM AS I 1 )IC KI"Tlt).
<br /> ums- I2uc IO FOR` I C C°e�I,AGEWrES
<br /> 1'
<br /> ."� -;ac;a sly , s= ,�aasdicre ., a, to€: and can be „ataiiied by ratting the State Board (916)719-242 . I'lle.
<br /> a 6ltey nurna :3?" nny be sS++�.,n,. 6W :.,u s aq;Ctenc, however, this number must be numerical and cannot contain any,
<br /> >alp'll ats ocal. it the to xelenc— I„ac„ the State Board to assign the facility ttcantlgec, please lease it blank.
<br /> FY 1S"HIGE CIES Y31r S F';U Y r ail.'1 11: LOCALEII.: IC'Y '111A1 I INSPEC;I "11114. A( I I'Y 1"0 VERIFY'111I3,
<br /> Af`t' TT A :N C F T111" FNF0164/"10N, TTITS A1111110VITON C NWY1'BE E ROC>E&SF I) IF 111H ()E C:C:C)UN."
<br /> a .F S NSI 1-711,'",.-,`D I1 it.. ..1114: LOCAL AGE.NCY ISPO SI LE,,1 JR 71W C:C) I3.,Ea'1"If:N OF°I'IfF
<br /> .I.`ccAL .,..a1 SIC V , ONLY IMPORMATtON BOXIL FOR VOR +` ' DI G ONE FORM W AND
<br /> 111 ta'€3 I,CT31tt f3 PiDY)RF-SS.
<br /> 51z't i` , a`V 011142)Rk11
<br /> t .F, 1,NA-17E R R S41I RC iS :)TSE C)1,T z .
<br /> CfO`2? 75ECa
<br /> E0, 170.0 527
<br /> r.; PA !a.,t,° i, C--, X723
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