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L Cine PQPM"A" stall be wr "tH IVY,-�','144" PVI UNCIIS, PERNwr 0MNC31S or an,,y IVACHYI-Y/Sfil F,
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<br />21 O. (lba, 'A' No a F"&Waim , tegydiess of dw rrum>wr C4 mnks hwaloj X the 01,
<br />I l for should b a Conq&wd Chor we PFRMYT APP11CANr oi- the IAICAIGENCY
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<br />4. Pome Cw i--crw',
<br />a We a hard mAS wd&g kmmmmn Y n aw MOM9 3 cnke
<br />TOP 0VF,()RPV1,'aAA'1h fr, ONIN ,,)N,'F 3T,'�`-N,1'
<br />11ark an (S) in As box nexi w Me hern tho bast dewribes the wream Me Rota is bWg emocted,
<br />J-1ACjj,,Trq-Y/srjj1 rNFORNmaICSs', S,- BE CONA-PL 47,,
<br />L Ruard narne mid addi,ans (phyajil oco/,,,ic,r, of Me
<br />"JUL Address MUST but a wlid phys. al jocabn imuding oj, We, rund Op code,
<br />11,0, BOX
<br />hyWe nearem cams street anj nom of the operamo-
<br />J -,onc, n,unh,,er �r/,s�"", ha'-ve, an awn co&, � Vn Qht nurnlyr K w some. "The "SAME" in propa, hxmhe
<br />I (lack Om appropote d3".. TYPE (H BUSAITS (ex� (X)RP()IZA`IV)N. INITIVIR.AL, cw_,
<br />4, Cheek Be api-n's,,pria"e y'ox for 'j"YPE, (si�
<br />5, If Facility/Site is locaud wiJbin an 1550eess"Mion at cuber Indian want Undo check the box maded "Yll",
<br />6, indicate the NUMBFIZ 1"-�`vNKs ",-0 S"If CK,
<br />7, Record the '11) a" a -,, nm in �,,�,�,xace
<br />Complete all joitre; in, thy sce5m, unks, aH hons am we name as SC C711ON 1; if the same. wric 'SANG? &S OWN? aeRw,,
<br />MN secdom Be serve to acch PRO-1-Al',"I"Y OWNEit""I"I'll, "'i'YPE fe)%,
<br />lff. 1''%PsK OWNER ,of
<br />Comcbm ad Renis 4 is ne; no, onto as sms am Aw 's'sunrue as SECTION, 1; If Be same, WK -SAMP AS OW117 mms,
<br />thy section, Be sum to f/AYN"�NCRSHIP 1TIVE bon
<br />INy BOARI) OF EOUATJZ.1VA110b1 UST �N'CH'tae,01" ACY,'OU,�NC NUItIBER (ARYS-l' Tk.C'(.-)MPTjn-vxY)
<br />Enter ymr Board of Tymo1,n4ai ORMI) 151 suarasy; Re account nturibarwhich is requiret] beforc y<)ur pertnit af,pli,�etkn
<br />can be proccon(b Rega,aemjr,;,-,, v.h, he 1310y", aajl Cnsune Bat you rill receive, a cluarterly storug,, fee Ra"n in rportin;,; thc
<br />K006 (6 mills) per Salta Re d" on Be number of 1plyms p1med in your 1511 The DOE wiH cWc pmem ewmN Roin
<br />p"ing Me strutne Re mi mums MH nm be sent, If yo�u do not have an metriunt number with the BOE or t<,r., t? .,e any
<br />gmstions, repisM% On be or exennqpficair, plane call Be FOE at 916-323-9555 or wrize to the B01-,-, at Me i"'iflowing nldress,
<br />Down of Eyindicatkin, Fs,i RC, Box 9,428,e), Sacrarticthre CA 94279-0001,
<br />11, P1T1'RO1,R'UiV U ' FUSAN,121AI, RES-PONSHINUTY (MUFF BE COINAPTAella))
<br />Identify the mcthod(r:) used by the owner sm1pr operator in meethig the Festexal and State fin anciat responsibility
<br />reqKmeM& USI's owned tj any liderY or S ageretyare exempt iron this requirement
<br />V1, ffiGAI, ',',TO11rqC!1VFfON ANI) B11,11-ING
<br />Check ONF, BOX An On Korea Gat wM be need for, TICY111 1,,E(5AA, j% -NT) IMIIINKG NUITFIC-AlIONS,
<br />APKICATn' NIUST SH3N ANIF) IINTE '111IF FICNI]PA 'A'S INDICMIEII
<br />,1N,K1'R1JC:I10p[ FOR 1,71E, 1,00A'.1, AGETNKCVSS
<br />Ile cmardy and jirrisdicAn nanihms are predriermined and can be obtained by calling the State Board (9Q7340045. Ile
<br />fmilyy nurnber may he acQued by Te &W ageocy; Kwevu, this nutrantr trust be marteryal myl can of ammin nny
<br />alphabcocab If fln, a,,cau agemg pmoste to Swe Baud to aNgn the Swifity creamer, please yane it blank,
<br />Tr IS iul!!, RESPC39NISIBUTIA, 4)111'111111,r)CAI,- AGFN9(,7Y TIMATINSPE CIS THEFACM�nY TO VERIFY '171E
<br />ACCURACY OVITIF, 1XV0,RNIA'110el, '17HIS A1T1JC,/V.'RON UtNN(Yl' RE PROCUSS,1-0 11,111F, SC C.»
<br />INRAVIBER In, NOT ITAK) 10 lxf)(,`Mf- ACHINCY IS RE-SPONSIBI.,U, FOR ITIE COMPTI,,'b1ON 01"PlIP,
<br />'l,OCAI, 1kG1TNC7Y US],F, ONLY' INFORN-CIV, WIX jNNT) FOR FORWARI)ING ONE FORM 'A' ATU)
<br />,A,W,-'X`VVFI,'3,) FC)RPA '13"(s) TV- THE M-Nd-OWINk"; AYINIHSF;
<br />ST)",111 OF CATIFOIRP41A
<br />,y1`/`tTi,,', WAI`13311 RICNOOURCES (X)NFROA, YX ARI)
<br />NATV'%, ING CENII.-"R
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