|
w
<br />INS RUC 71` ONS EDS COMPT.LE"FINGz FORM A'
<br />ENI -WAIS
<br />i, On— i�t:iRN.l "A" shaH be completed for all NEW I" :? I'I , IT13Rmn, C H NGEN or any FAC'ILITYJSrFF
<br />INlk)RMKI1ON CIIANG ';,S_ kw V
<br />2. SU B £1' ONLY ONE (1) FOR "AV for a Facility/Site, regardless of the number of tanks loc.Eted at tiu sitc,
<br />3. This form should be completed by either the PERIMIT APP1.IC"A 1' or the L,t3CALGPENC:Y iJ;tiDF`st26R0 iND
<br />c or print clearly allrequested information. -
<br />I_:X, a hard point writing instrument, you are making 3 copies.
<br />VW t'C`,' WARK ONLY ONE 17I tiT"
<br />Niark an (X) in the box next to the it'e'm"that best describes tate reason the form is being c;oruplete(i.
<br />I. FAC,f1, IX/sl js', �"MXI W A id -SS USF IIIA COMP1. .I3)
<br />L Record names and address (physical location) of the underground tank(s).
<br />NOTF3 Address MUST have a valid physical location including city, state, and zip code.
<br />PP OC : 13O . E3I..E2.S ARF Nar Ac a[wm.I?
<br />Include nearest cross street and name of the operator.
<br />2,... ,I'hocte number
<br />p must have an area code. OF
<br />the night number is the { me• write "SAME" its proper locanon
<br />3, €herd, th ` ' ro -sate box for TYPE OF B SINESS OWNERSHIP ex. Cow C7RA ION, INDIVIDUAL. ew.)
<br />4. Check the appropriate box for 'I`YPEs OF BUSINESS.
<br />5. if Facility/Site is located within an Indian reservation or other Indian trust lands, check the 'nos marked 1I3S`
<br />6. indicate the NUMBER of TANKS at this SITT?.
<br />T Record the E<.P 4. Iia # or write `Nk)NE" in the space provided -,
<br />II, I°ItC)I EWI'Y O NI4R -INFORMA71ION & ADDRESS (MUST BE f
<br />Complete all items in this section; unless all items are the same as SECTION L if the same. write 'SAME .AS SrIV' across
<br />this section. Be sure to check PROP RT'Y t WNI-,, SEIIP TYPE box.
<br />HL TANK OWNER INFO i = ,A DRF a S (MUST BE C O PLFI )
<br />Complete" all items in this section, unless all items are the same as SECTION 1. If the same, write "SAME AS sl i ;,ss
<br />this section. Be suxe to check 'I:A O .IR,SII P `I X1 1? box.
<br />� Er I tiAI ZA170N LIST' S-rO G I E ACCO T E S ° iBE P11 I1 ))
<br />Enter your Board of Equalization (130E's) LIST 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 in reporting !hc.
<br />ti.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's. The T30E; will code, persons exempt Trott. .
<br />paying the storage fee so returns Mit nbt W Iskmk. If you do not have an account numbeikVeith ihil 13CIi"? c t " oia"lt ate ,its '
<br />questions regarding the fee or exemptions, please call the BOE at 911-323-9555 or write to the 130E at the folltrcvrtt(y rddr ss:
<br />Board of Equalization, Environmental Pees Unit, PD -Bbx 942$'79, Sacramento, CA 941'79`461 a i .
<br />V. Pj-,TROLEUM. U,917 TINANCIAL. .SP, NSTBIIXFY ( usr Bit co ix -1 m)
<br />Identify the mei od(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. US'1's owned by any Federal or State agency are exempt from this requirement.
<br />L 1 1C,AL NOTIfaIC A'nON AND B111 INC3 ADI3RENS s. t
<br />Check ONE,- BOX for the address that will be used for 1301'111 L ° AND 111111 I G 2 C7CTFK A°I"IC➢NS.
<br />APPLICANT M UrS T' SIGN AND DX11i THE FORM As INDICA D.
<br />iNStMU(."1"ION F() '171113 LOCAL AGENCIF-S
<br />The country and jurisdiction numbers are predetermined and can be obtained by calling the. State Retard (916)739-2421. "hhe '
<br />facility number may be assigned by the local regency; however, this number mustbe numerical and cannot contain any
<br />alphabetical. If the local ageney prefers the State Hoard to assign the facility number, please leave it blank.
<br />Yr IS 11111S,113I OF TII ? LOC:AI, AGENCY 'LINE' I,NISPFXTFS 111E FACLl 1"Y TO VERIFY "I IEi
<br />A I;Ii C' 0F'ITIEi INFORMATION. ITHS APPL,IC A°I°[tiN CCRANNO'I' BF i'ROC'I:;S,SED IF ITI ? E AC:Ci°< UNI'
<br />NUMBER IS N(YI' 1111,11U) IN. 'IT I .I,(1 ' L A(YIIN(,-'Y IS RESPONSIBLE FOR 11W. (°C3MPL .C)N, C$it 1 • ., .,
<br />" .C) ° . A(;I N(.'YUSI< O I ` " . 'n6 A )IzOR I,''O A INC"s ONli l?(1 ° ^ A'A
<br />AS,SCICI1 17ED MR "I3�(s) TO THEE WI itsORE S,,S.
<br />S A` 1 OF (:Al IFOR IA
<br />C/o &wTuLps,
<br />DATA PRO("Ii&,SING C,'I N173iL
<br />PD. BOX 527
<br />PARAMOUNT', CA 90721
<br />
|