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I"a-1,517RUCITONS CIII C;4dtII'I.I,"FING I'2k€s.3M "AV
<br /> ., One FORM A .:£,f he ck, ,fe s e for all NI,W I°I,IaMI`S, MIoM CIIt NGI S or any VAC°ILr y/s t ;
<br /> INIC.ItIMwC1t4lat C..arANe,?s,a,
<br /> S'UI£IMEr CINE W" (WE (,q FORNI .`s" Por a FwNVSW, regardless or the number ol. s<anks tr>e°."s m tt,., We,
<br /> s, 'f'l.s£ f,,£:_ be c xrr,s £., by (Glace the MIRMITAPFUCAITEor the LOCAL A(;I,,,N(,Y kfND1 d=. sa>ta£ D
<br /> 1AMP air S I F e. R,
<br /> TOP Y.,P I;.df' f a.I'a,I t'rI: f',I,A�.flK ONLY g,NI"'
<br /> xdart, mi (X) in tome Lor next to Me imn; tMt best des,ribtx the reason the form is tieing cornpletch,
<br /> UA Ir I f'/STIR IN `IT N & ADDRF S (MU 1`All C O 31111)
<br /> A
<br /> W ICmcmd-ante and adom s�(hYshm! location) of the underground l ank(s).
<br /> ,\.�.°.; A',..3,. ,..: ,�,x.,`°A. Iiia. e a >`n,E:i.£"d physical l.tc.:3d?:.Y, k':"€c1LS{fHY3g C9t�`, 4t'u'tt;. il.'2U -lip C€>£[£',
<br /> PSI DOX sVIJNHlU,'SS Affil NOT (T17ICAIIII?
<br /> Arluac saes st cows ..tmet and trarne of the £,rerator.
<br /> Z p4me number r< "have <ar aea cods.,. If M .e,t1 r 4Er se°r 0 Ac t,me, wow MME, €,r proper W at€am,
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<br /> Werk the fe .€,><a t box „. r PF. F ftp .,_ ,..;dd ()WNP/R°;f'Iff t££. (,(:)RI1OItA'I0N, If?lIA IF}U f, cic,)
<br /> A CFfr.£K, W sqvmrprim r`+,:7x frr Tztff, OF %i sad%„SS,
<br /> . if e a,.a9=tf;`Ur is located 050 an Indon r<;s..r,.,hn or other Indian trust lands, check the box marked 5'f%'%
<br /> it. watrsrsss e tz2£ asE TANKS at this SITIn'.
<br /> Fla v.,.£a We f.,'f..'a, 3fF # or wteWNPAP Be were pa£oWd,
<br /> IE. I'ROrls,r£f Y OWNRR INI:'CIICMaaa1143 &AJ)D I:SPS INICII�� III; C II PLLrn II
<br /> r tunplase all mores in tl`s`n. swVx ,a.(m all ,"erns, are he same as SECTION :1 if the same. write 'SAWAS'SAW19117
<br /> ECS➢., ,;,:..,.te.t;ri. Ba,',', S[i.r `5 Beck n,xROWtCd£ reWf'",f,e_ UP TYPE. box,
<br /> HE TANK OWNHII I: IBICFa4,o'1' .FsF a:r ADDRISS (eslJSF rllf MIf f LU-3`D)
<br /> 2Con"' �l ten ad be-s-,> in A .�,_
<br /> s :€, ...,,£, x� Ams s �,re the z,,a ne as SEC HON, I FT a'If the same write "SS STI rwnvsa
<br /> 6 k swim.. S:e .> re ..o auk ,',d A''F`v rY PH,box.
<br /> M BOARD OF EIINJATIZAITIONClfv 'FPORA FI! €alLf CC.'OUld "NUlOaR Q_ e C, jrI
<br /> Board of Equadcration (?aOF,) UST mor e fee aacccunt number which is required before your lse reit appli afion
<br /> n be procund, Rcostraficin whh h,, JXQ M9 ensure, Mat trews will receive a quarterly storage~ fee ,£twn in .?fz£>;°s ng sire
<br /> t a sums) per gamon Use Che on cc nwocr of gallons placed ars year UgTa� 'Ehe BOE will code perscms exempt 1`s°ea€aa
<br /> E,"f 11w storage fee so returns QH r;..; he s€:rat., Ii you do not have an account number nth the BMi or d you We c rmy
<br /> qu, z:oa s rc;garding the he or ea nt ums Iease cab the BOE at 916-323-9,555 car write to the BOIF at Be fo.owing addr f s"':
<br /> Bond of Equalization, -U£ irorene n.ar .'era Last, PD. Isar cA1287% Sacrarne tce CA e94279-0001.
<br /> V. I'It;l€tsMal,I.t-pA U'S-F FINANCIAL C,IAL RF,PONfflfsll.I`F`y` (MUST II:f'n
<br /> 1mvilye the me £a'sa 3,N by We urnu an djor otennor In meeting the Federal and Stam financial reTonsibUit7
<br /> gg ay.ea_osp_ ;ry Ig.g as e y a:3k tedev�ryat o£ yi�:ea agency are exempt' front this requirement,
<br /> I. 8sn.aC&AL a�'f,.111F3%...t"4.�SRON AND %RUNG a�.T3DF-'9_ .S
<br /> Check s.INU WX for tate ,ae`dn' s, that -s€rl the irises$ for WITH 1J,,GAL WNUD BILUNG NUIT110VITON&
<br /> APPILIC.F rt"I INIUSV SIGN AND Dr TF,`I"aff, tet:RNR AS INDICAITID,
<br /> If`ISI".RUC:.aICIFS FOR`I"IIT LOCAL CII:fNUHS'
<br /> I'hr counry and jurisdiction numbers are predetermined and d c<an be obtained by calling the State Board (910)t`FdIF 2,171, The
<br /> facility ility na rsber bay be ass,gned by the kwa0 aga'nr . however, this number must be numerical and cannot contain any
<br /> toth-abetsral. If the local agen£ , € l£r.. Me Sone Board to assign tate facility Humber, please leave ;t blank.
<br /> III is THF, :Et-MAN IIIIII,T1 (Ar" ;IT lU", h.a,y«`s;I.. AG',RslfC'y THAT I fSIFIR-I'a 11II4CI 'I ) IT, ' III
<br /> ACCURACY RACP. CIF TIII INI OR IA a a'I ;. IIIA, Ae°'PLIC",I`t O I CI `BIT PROC Y—SPI) IF 111II II4II4`>ACAt OUNI'
<br /> Ia& :1[hp .IS DCII 1'`ff f:,I;II INESICf IWAL AWNCT IS ICIiSPONSIBIM FOR111F C"t7MI'LIz °[C:IIk OF 11113,
<br /> "I IIC.,:L ACI€VIAC Y USI{ t Ilsf Y' I I C""=lla4A tO W,,)W,,)X AND FOR FORWARDING OI IUR "A'AND
<br /> ASCIt,',Ifk"IT!'D DORM "B'(1)TO A DIMS.,
<br /> SNIT,OF CALIFORNIA
<br /> r II"r'I I WATTIf£ ICtTOI,ITK I IS C C) IIIWWARID
<br /> PD, BOX 57
<br /> PARA-MOUNF, (A 90723
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