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ININW POF t «PLE-IING TIORI I 'A'
<br /> 1. One FORM "A" sh,111 be completed for all NEW PERmrns, PE.RM111' CIIANGUS or any FACILITY/SrIV
<br /> INFORMA'17ON CHANGE&
<br /> 2. SUBmrr ONLY ONE(1) FORM 'A* for a Facility/Site, regardless of the\vqumber of lank" localed al Ihc, sit,;.
<br /> 3. This form should be completed by either the IPCAL AGENCY 1,JNDURGROUND
<br /> TANK INSPE(n'Olt
<br /> 4, Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument, you are making 3 copies.
<br /> TOP OF FOW- "MARK ONLY ON[," 1`1141'M"
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILrrY/SrW. INFORMNITON&ADDRESS (MUST B14 COMPLI-TIED)
<br /> 1. Record name and address (libysicil 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 NUMBERS ARE Nur Acxmmnut
<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" its proper location.
<br /> 3. Check the appropriate box for TYPF OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVID(J'AL, cic)
<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
<br /> L Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A. 11) # or write "NONE" in the space provided.
<br /> 11. PROPERTY OWNER INFO 11011& ADDRESS (MUST BE COMP11z][10)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAM14"AS SI'll,'" across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE; box.
<br /> III. TANK OWNER M*ORMKIION & ADDRESS (MUST BE COMP117M.1))
<br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME1 AS SITE across
<br /> this section. Be sure to check TANK OWNFRS1I.IP'IYPE box.
<br /> IV. 130ARD OF Fj0UAI1Z/VnON USI`9FORAGE ACCOUNT NUMBER(MUST BE COMP113' .0)
<br /> Enter Your Board of Equalization (BOE) U91'storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee :return fil reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from
<br /> paying the storage fee so returns will not be sent. If u do not have an account number with the BOF or if you have any
<br /> paying YO
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following; address:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879. Sacramento, CA 9427.9-0001,
<br /> V. PETROLEUM USF FINANCIAL Roo poNsmilIXIT (Nuj,,;,r BE comptuml))
<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 Federal or State agency are exempt from this requirement,
<br /> VL LEGAL NO'11FICA'nON AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING N(YF1FI(W.rI0NS.
<br /> APPLICANT MUST SIGN AND D/V11.1,111E FORM AS INDICA111D.
<br /> IN91RUC`11ON FOR'11i1:? LOCAL AGE.NCIES
<br /> The county 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 /> alphabetical. If the local agency prefer-, the State Board to assign the facility number, please leave it blank.
<br /> rP IS 171E RE SPONSIBIIXI'Y OF11tE LOC,,V, AGENn' TIT,�T INSPI-1-I'S'ITE FACJIJYY TO VFRjJ1Y "ITIS
<br /> ACCURACY OF 111E,INFORMA'110N- 1111S APN,l(1',,'0 lk) CANINOT 13F PRO(JiRSE'D ETA 111E 1101:1 A(X'Olj?Vl*
<br /> NUMBER IS N(Tt' FILLED IN. DIE, LO M,AGI NCY IS RFSIIONSIBLJs FOR`TME COMPLVIJON 017171F
<br /> 01,0CAL AGENCY US13i ONLY" INFORMATION BOX AND YOR FORWARDING ONE FORM "A" AND
<br /> ASSOCIA173D FORM -W(s) TO 1111,1' 1iO1,1.0WING Al-)DRISS.
<br /> ,517VIII OF CJ1IJFORNIA
<br /> 131WIV
<br /> WN11,R RUSOURCE-S COMIROL BOARD
<br /> c/o �W-Iuirs.
<br /> DATA PROC13,%ING CENI'ER
<br /> P.OF30X 527
<br /> PARAMOUNF, CA 90723
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