|
IMINRUCITONS FOR C'OMPLE-11 NORM -A,
<br /> GENERAL IN9I'RUC`I7ONS.-
<br /> 1. One FORM"A'shall be completed for all NFW PERmns,PERM171'CHANGES or any FACIUI'Y/Sril�
<br /> INFORMATION CHANGES.
<br /> 1 SUBMT17 ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the sate,
<br /> 3. This form should be completed by either the PERM rl'APPIICANT or the 1 AGIINCY UNDERGROUNI TANK
<br /> INSPF)CI'OR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies,
<br /> 1701'OF R)RNh *MARK ONLY ONE TILIM'
<br /> 1. Mark an (X) in the box next to the item that best describes the reasqu_the form is being completed.
<br /> I. FACIlXI-Y/SFI-E:INFORMATION&ADDRENS(MUST BE,(X)MPLET110)
<br /> L Record name and address(physical location)of the underground tank(s),
<br /> NOTE: Address MU-ST4ave a valid physical location including city,state,and zip code.
<br /> P.O.BOX-NUMBER ARI?Nbrf ACCEFFABLK
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME" in proper k,-m;on,
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex. CORPORATION, INDIVIDUAL,etc.)
<br /> 4. Check the appropriate bow,forTYPE OF BUSINESS.
<br /> 5. If Facility/Site is located'Z)n land within an Indian reservation or other indian trust lands,check the box marked 'YES",
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the ETA, 11)# or write "NONE" in the space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ATYDRE&S(MUST-BE COMPIJ71VD)
<br /> 1. Complete all items in this section, unless all items are the same as SECI'1ON 1: if the same,,write *SAME AS S11,U*across
<br /> this section. Be sure to check P1i0l1FR'IY OWN ERSI fill TYPE,box.
<br /> III.TA OWNER INFORMNOON&ADDRE&S(MUS-I'11F,COMPLFI(T"D)
<br /> 1, Complete all items in this section, unless all items are the same as SI:ICTION 1; If the same,write 'SAMI!AS sm,
<br /> across this section. Be sure to check'TANK OWNERS111'e'I'VI'll box,
<br /> IV IIOA[tDOFIaQUAIIZAIIONuSr,5]y,)RACEII!LzA('CA)UNI-twt FIR(MtjSI'lli'COMI'll'T19))
<br /> Enter your Board of Ekjualizaiion (B(A,"; USTstorage fee n,,,,-ber which is required lvfort,,your permit application can
<br /> be processed. Registration with the BOF will ensure that you receive a quarterly storage fee return in reporting the 50,006
<br /> (6 mills)per gallon fee due on the numb -of gallons placed n yo,ur US71s, The 136H,will code persons exempt from paying the
<br /> storage fee so returns will not be sent. If lou do not have m account numl,cr with the WE'or if you havo ani questions
<br /> regarding the fee or exemptions, please (a;i the 8101-1 a-1 uwrite to the BOE at the fcllowringaddrcss; Lard of
<br /> Equalization,Environmental Fcos Unit, P"), Box 942379,Sacramento, CA 94279-0001.
<br /> V- I.I.iGAL NG71'IFICKI'ION ANT)1111.11NO ADDRESS
<br /> 1. Check ONEI I3)X for the address that will be used for DOTTY 1-T.X;AL AND'RI1JING N(YI7114647Iow
<br /> A 411311("N.1'MUST SIGN ANY)DA71171111 Ik)RIW AS INT)KA115),
<br /> M51 RUCTION FOR 11T.F.LOCAL AGINCIES
<br /> The county and jurisdiction nv�r�bc,-S are predclernund and can be obtained by calling the State Board (916)731}-2-121. The
<br /> facility number may be assigned by the kr-,al agency,; h o.wcvtr,this number must be numencal,and carmot contain an alphabet. If
<br /> the local agency prefers the State it?
<br /> '.lankI I
<br /> e Board to assign the facility number,please leave it .
<br /> WS,,T"i,K,"NITON CANN(YFBE PROCE-W,"D 11711YE BOE ACCOUNT'
<br /> NU9,1Q1iM 1S N-,DTp,1IJJzD IN. '111F l t a,AG;,NCY 1`1, RUNPONSIBIX FOR 11111 COMPIJIION OF11111'LOCAL
<br /> AGv�NC'Y UFF ONLY'INMWV/,'J; 1307V91"WARDING ON13 DORM'A*AND ASSOCIXII3D FORM
<br /> .B'(s)TO 411E FOLI OVjING -Nil,
<br /> KJA'f—OF CA[ 11,Oi,NiA
<br /> SJ'A: WiVII"o, lRCI x5 °-'ONFROL BOARD
<br /> C/0 S W.VH-Ll;
<br /> P.O.IX)X 527
<br /> PA. AMOICA fX)723
<br />
|