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1 1J('I1 NS MR COMi$I1—IING FU "ice
<br />GENEPUAL INWRIX-TIOrl -
<br />i. One FORM 'A" shall be completed for all NEW PERM(I'S, 1'13 T" CHAN 0% or any Ir C111IT/SrIT
<br />1NF()R.MA`rI0N C HANG rS.
<br />1 SUBMIT' ONLY ON (2) ITC?f " for a Faciliily/Site, regardless of the number of tanks located at the: site,
<br />3. ;' 'his form should be c€ rpleced,by either Cher P I RINUT ,f PPI1(`. °)r or the LOCAL„AGWANCT UNDERGROUND TANK
<br />IS1'I 70R.
<br />4. 'lease tyl e or print clearly a`l requested infortnaation.
<br />3. Use a heard point writing ir:stnmr nt, you ace making 3 capies,
<br />FOP OF , RNC- "MARK ONLY ONE ?M”
<br />1. Mark: an (%) in the box next to thce item that best describes the reason the form is being completed.
<br />1. I�t�C L /SrI l 312. tt`FI0 DDRE S �" I3H? lei l�I �[�
<br />I, Record name and address (physical location) of the underground tan (s).
<br />NO'11:: :Address MC SI' have a valid physical location including city, state, and rip code,
<br />PD. 13OX I` UMDER ARE Cr1' .(`C."It1"FM1I. ?
<br />Include nearest crus street,.and name of the, operator,
<br />2. Phone number must have: an area code, If the night number is the sante, write "SA.4 E" in proper ioc atiom ,
<br />3. C }neck ti e appropriate box fc>r .1. "F?i: C'IE i3C! it i iy C)t tSi it sllfl' (ex. S;C_II2PO Rr1'l1(.)N, INDIVIDUAL, etc.)
<br />Check the appropriate; box for `1 PF, 01' IId. SIN SS.
<br />5, If hacility/Site is located or lard within an indian reservation or other Indian trust lands, cheek the box marked "YES".
<br />ti. Indicate the NI)I,t13[:>R of ".I"ANKS at this SITE,
<br />Record the ETA. 11) or write 'NONP," it the spare provided,
<br />11, RR PFK]'Y OWNER 1NI� - A`t1O AT)D E Sjw 13F I* �h;1I's }.
<br />li
<br />Complete all items in this section, unless all items are the same as Si;1>I' ON 1; if the same, write '!SAME AS "I7" across
<br />this secti,om Be sure to check PR -0111. IRTY OWNS iuif'i"vpt' ', boxa::
<br />III TANK OWNER INFORMS11ON & DDRi:R, (MIKI' BE C OMP1,11I"I?1))
<br />I. Complete all items in ;his sect=or; unless all items are the same as 4I"sC7I'[ON 1; if the same, write "'S'AME AS SUE'
<br />across this section, Be sure to check .1. . € WNERSIUP 1'YPF box,
<br />IV BOARD OF l;QU 11ZKt'I€ N usrM, RAGE KU.3 ACCO Nr NUMBER ( usr B11 m urilll))
<br />l'sntrr your Board of Isclealization tztCtF} L I" storage fee account numberwhich is required before your permit application can
<br />be processed. Regist;rmion with tire; i'10f�' will ensure that you will receive a quarterly storage fee return in reporting the W(
<br />(G mills) per gallon fee due on the nunO.-�er of gallons placed in your U STs, '1`he BOIs will code persons exempt from' paying the
<br />storage Cave so returns will not be sent. If you do not have an account number with tike BOF" or if You have any questions
<br />regarding the fee or exemptions, please call the BOE at 916-739-1582 or write to the BOE at the following address: Board of
<br />Equalization, Environmental pees Unit, 11,0, D,)x 942879, Sacramento, CA 94279-Mfill,
<br />VI...C3AL t £ I`I (1VI N AND BILLING ADDRESS
<br />1. Check ONE BOX for the address that will be used for 13 Y1 1 11XIA AND DILLING NU111rICIP11ONS.
<br />.I"PLIC'.ANI' M . Sf SIGN AND IWI 'I'IIE FORM AS I DI(WI'I 1
<br />`I -he county and jurisdiction numbers are predetermined and can be obtained by calling the State 11oard (91,6)7 39-2421, The
<br />f ac°ility ;cumber may be assigned by the local agency; however, this number must be numerical and cannot, contain an alphabet. if
<br />the local agency prefers the State Board to assign the facility number, please leave it blank. l
<br />fI:` IS'IsIIi. RIs,' PONSII3ILTI"Y f1F'I ti:t:i< LOCAL iY[iI?� C.Y "171 ,1< SI*izC IS `T 111? 3r tMlIT TO VERIFY TITS
<br />CC Il . C,::Y OF111112i I:NFOP MA7110M '17115 PPUC'.A'nON (:A (Y1° 131? I"ROCI "QED IIS UTE BOB AcC)C C
<br />UTSBl R is Nar nI,In) im um I ? if ocm, AGENCY IS RI ISPONSIBIJI IA()R 11111 C OMPUTITON OF 171ii-0I,C1( I,
<br />AGE N(,Y USE ONLY' INFO lt,`:I`[Old 13OD 'CAR FORWARDING ONF IX)RM " " 17 ASSOCLA71,113 FORM
<br />S`I`A'171 ']MR. R1ASC.7URC ES comrkoi, BOARD
<br />C/o S.W.n11P.&
<br />P.O. 13OX 527
<br />a
<br />PARAMOUNF, CA 90723
<br />
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