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<br />INS`FRl X'ITONS FOR COMP11 EIINGIC 'A'
<br />GF .RAL INS71'RUMON'Sk
<br />1. One FORM .A" shall be completed for all NEW PERMI'I'S, PERMn'CHANGII-S or any FACILTI-t/Srill!
<br />INFORM,NIION CITANGILS.
<br />2. SUBMrF ONLY ONE (I) IX)RM 'A"for a Facility/Site, regardless of the number of tanks located at the sits:.
<br />3. This form should be completed by either the PP.RMYF APPIICANT or the 1f3CALAGINCY UNDEIRGROUNI 'PANIC
<br />INSPEC7170R.
<br />4t Please type or print clearly all requested informtioti.
<br />51 Use a hard point writing instrument, you are making 3 copies.
<br />FOP OF FORM: 'MARK ONLY ONTI TIEW
<br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />1. FACIIrFY/SrM ININORMA-FION & ADDRILSS (MU9r BE (X)MPIHI.10)
<br />L Record name and address (physical location) of the underground tank(s)`.
<br />NCYFE. Address MIST have a valid physical location including city, state, and zip code.
<br />P.O. BOX NUMBER ARE NOT A(XIWAIHJ�.
<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
<br />3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex, CORPORNFION, INDIVIDUAL, oto.)
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located on land within an Indian reservation or other Indian trust lands, check the box marked
<br />6. Indicate the NUMBER of TANKS at this SITE,
<br />7. Record the E.P.A. 11) # or write '.'s'ONF in the, space provided.
<br />11. PROPFRTY OWNER INFORMA71ON & ADDRE-sal (MUST" BE COMP117.110)
<br />1. Complete all items in this section, unlcscs all items-aTV fire s aata SECTION. I:- if the samcwi e 'SAME AS'ST1.'Eacross
<br />this section. Be sure to check 111WITRTY OWN* C1tSfllP"'l7YI' box.
<br />111. TANK OWNER INFOKCMA'JION & ADDREI�S (MUSI'B
<br />7
<br />1, mvicte items in this section, unless all items are the same SI.ICTION 1, If the same, write 'SAME AN Sflli'
<br />this tion. Be sure to check TANK OWNE!ZSIHP"TS bow.
<br />IV 1 -1,11 , IJVFK)� U 17 SMOPAGE 111,33 AC(AXUKI, NLI JR,. VA.)WLHJVJ),
<br />Enter your Board of Equalization (BOF,') UST'storage fee accouq?#umber which is regired hoon yoi�r neamit
<br />� will ensure that you it] r6ccive o rage T' tj �19 Tufe��'
<br />be processed. Registration with the BOI �v \.,
<br />(6 mills) per gallon fee due on the number of gallons placed in you,- -''dc pcl,SOM
<br />storage fee so returns will not le sent. If ywi do not have ,,n account n0mher Urffou'
<br />regarding the fee or exemptions, please, call the BC)Fat 916 -39-2,592 write in'the IAAai
<br />Equalization, FIrrEironrncnral F(,us Unit, P 0. Box 94,'N -T), Sacramento, CA %1279-0001.
<br />K 11NIAL NffI1FIC-A'11ON AND 1311JINGi AW)1"RV-1-;S
<br />L Check ONE BOX for the address that will be used for IXYUI I-EkiAL AND B111,1NO, NOTTFICATIOW&
<br />APPUCIANI' Wisr sicAN AND DXFV 11 If! FORM AS INDICA710,
<br />INSTRUC17ION MR 111`11 LOCAL ACHN(Ile;
<br />The county and jurisdi, tion nvrnbem, 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 l num be'must be Wicrical and 1cannot .contain atialpliabet. If
<br />the local agency prefers- the Stale Board to assign the facility number, please leave rj�4
<br />!ank,
<br />rr OF111F 1,0('AI,A(;EN(,Y'IIIA'rlNSTIX-'rS'IIIEFACIIXI'Y'1'0 VERIPY'11W
<br />71115 APPI,u� I TON CANNCYI` BI PRO(MSSE 1171TIE110FACCOL)w
<br />IN, '111111 LOCAL AGENC)" 1,; RESPONSIBI -F FOR1111H (7OMP'IJr11ON OF °1711? *LOCAL
<br />Ao i,-, --Y T °`F ONLY, INIKIRMA'110N BOX AND FC ONl; FORM W AND ASSOCl/V110 FORM
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<br />KI'A1E OF (AlIFORNIA
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