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<br />1N,5rRLJCI7I0NS FOR COMPLETING Ti"ING FO "1V
<br />GENERAL IN51'RUC11ONS:
<br />1. One FORM "A" shalt be completed for call,IEV PI?R, PE'A 1'1' (31ANGEN or any h C:ILmy/sil7a
<br />Ii I'C`)11Pa11Y1ION C"IIt1 ZCsO'i.
<br />2. suBmtrit, ONLY ONE (1) )R "A' for a Facility; Site, regardless of the n n bcr oftanks h:)c atc�d at t( ac
<br />3. "'Dais Berm should be couple d by either the IbIsR\Ifi' f3PPLIC".A °II'-or the LOCAL AGIzN(,Y LJND 'R(;R0t*ND
<br />'DANK IN SPEC'I'Ol
<br />4. Please type or "print clearly all requested information,
<br />5, Use "xa hard point writing instrument, you are making 3 copies.
<br />TOP OF FORM. 'MARK ONLY ON11, ITEM'
<br />Mirk an (X) in the box next to the leans that best describes the reason the form is being completed.
<br />1, Record name and iddress (physical location) of the underground tank(s).
<br />NC)"1"E: address MUS)' heave a valid physical location including city, state, and zip code,
<br />P.0. BOX £dii MBT1'[&S ARE (Yr 1£ " : PIM IX-
<br />Include,nearest cross street anti name of The operator,
<br />1 Phone number must have an area code. If the night number is the same, w-rhe `SAME,," in proper toca-tion.'�
<br />1 Check the appropriate box Rr)r'I`XPE OF BUSINESS OWNERSHIP (ex. CORP()RA'l°IO , INI)I3IlC7I AL- etc.)
<br />4. _ Check the appropriate box for `E YPI Of' 131.,SINESS.
<br />5. If Facility/Site is located within an inch an ;reservation or other Indian trust lands„ check the box marked 'k tsS".
<br />tic Indicate the NUMBER of TANKS at this SITE.
<br />7. Record the 1`s,P.A. ID # or write "NONE" in the space provided.
<br />H. ' PROP "sWIT OWNER 1N1k)RMN110N&.1 13 &S (MUST BE WIAPLIu"1!D)
<br />Complete all items in this section, unless all items ars; the same, as SIi TION I9 if the same, write 'SAME AS Si'tV—,,at too,:., ,
<br />this section. Be sure to check PIZf: PEW17'Y CBWNf:RSHIP TYPH, box,
<br />111. TANK OWNER I; P"O M A°I"1C7N & ADDRUNS(Miy�C BE O PIH.IT0)
<br />Complete all, items in this section, unless all items are the sante as S C"1': ON 3; ,If the same, write,..S S : ASI1"I." across
<br />this section, Be suree to check TANK OVMMSHIPTYPE box.
<br />. BOARD of I OuAlfr.. '1"'iON US-17 SPORAGE FEE,,ACCOUNT NuMaPp, (MUST 131's
<br />Enter your Board of F.qualization (I3Cliv) t ST storage fee account number which is required bcafore }coin° Permit <xt?;shceation
<br />can be processed. Etegistration with the BOBwill ensure that you will- receive a quarterly storage fee return in reporting tits
<br />${},006 (Cs rraills) per gallon fee clue cies the number of gallons placed in your US'Ps, The BOB will code persons exempt from
<br />paying the storage fee so returns will not be sent, If you do not have an account number with the 1101 or if you have any
<br />questions regarding the fee or exemptions, please call else BOE at 916-323-9555 or write to the BOY,," at the following a ddrs ss:
<br />Board of Equalization, Enviromnemal ace unit, P,O, Box 942879, Sacramento, CA 94279-0001,
<br />!T_ PETROTMum usrANmil, ISI �"�E oNsi1311ny usr III comp , raia)}
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requir means:'' U is owned by any Federal or State agency are exempt £:matt this. requirement:.
<br />V1, LEGAL NO'1714("AITON AND 4111ING lkDD I S
<br />Check ONE BOX for the address that will be used for B(YI11 1 s° i p AND B1U.JNG 1 CYI'I1T1 `" ITONS.
<br />APPucAbr ' musr SIGN AND DAIS IIIA IsORM AS INDICKIED.
<br />IN,517RUCHON FOR THE LOCAL AGENCIES
<br />'rhe county and jurisdiction numbers are predetermined and can be obtained by calling the State Berard (916)739-2421., "rhe
<br />facility chamber may be asssg ae t by the local agency; however, this numbermust be numerical and cannot contain arty-
<br />alphabetical, It the local agency prefers the State Board to assign the facility number, please leave it blank,
<br />rI" IS "Mill SIIIII 1 01711111 LOCAL AGENCY 'n1/VI` fNSP I 'I "1E I"Y I'C? Vimey THE
<br />A(,'(,'LrRA('Y OFTHE IT'IITORMA7I ICJI9d ills a PPI,T W171EJt CANNOT BE PROC ESSE0 IF 'Ill IIC)E A(` I.T '1'
<br />NUNUHIR IS NOT E"II,I I IJ IN. '11JE E.CJ(..I. AGMCY IS RESPONSIBLE FOR 11W, COMPLEUTON OF THE
<br />wl.,O( l- AGINCY LISE, ONLY' INFDR lft'ITON 1 ,tX AND FOR FORWARDING ONE, FO "ft" AND
<br />IWII? ' "1'1',R RE-SOURCI&S CONTROL BOARD
<br />C/o smiLap-&
<br />DA`rA PP,CJC ` G C' Wil$
<br />P.OBOX 527
<br />PARIAMOUNW, CA 90723
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