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<br />'NF Ge i
<br />101y"vU)OCUON IAN -,-,,,A,
<br />2SUBIJ-111 ON11Y WNIF'40) K)WA, 'A' fora
<br />3, 11hs,,,, t,orin sbollid he conipleted by e,lther the I'FiMJ- .,%I A,t i E' N C U N Gg�k r,
<br />res _ w 6_-ulh aicqkxcs,ed inflircvj„�,�
<br />you Arl,
<br />'FOP Of' FORM-, `N(ARK ONE 'r I EMV
<br />an (X� hn tho,..,',., to flne that best oi' l Conlpi t ll,
<br />1. I?AyJ1,Jf1-Y/S1'J'1f INFORMAJ10-1-4 & ADDRE-SS (MUSF IiIi (Defl,?i, 1,31,1-1,vlt
<br />1, Peord mijell., and, elll]�Ces (physical location) of 1''lie rld
<br />NOJJFI: Add1rc,,-,,s \,1U'S'i'bavc a valid physical lo'calit')n
<br />1" O, BOX NUIMBERX ARE NO(r
<br />hich-co'c liCartol cross lareat and name of the op -1,-' �,lT%
<br />2, Pborte numb(.r most htwe all area code, If the night nu,nnh,,,i le tile salIc- wlll,� -"S/),%W" ill proper koconon,
<br />3. Check the appropriate box for 1`1'E OF BUSINESS 0-\V1J21ySHlP (i,%-, JNl')IVll)UAI- etc,)
<br />4. Check the appropriate box for JYPJE OF B13SE"N'E"�SS,
<br />5. If Facdily/Siw is located within an Indian reservation or lnoi,,ui u -Alt lands, 11tcck dw Oox markod
<br />6, Indicate the NI"MBER of 'YANKS at this S111 -L
<br />7, Rect)rd the I-P.A, 11) # or write "NONE"" in the
<br />It. PR(WRIC17Y OWNFAI, 'iNWOR-MA37ON &ADDR1!-,3.S (mustr sl-,
<br />'
<br />all Oe, ill th,l� unicss all ncins lnre tol, a s S1 7 11 -Y N 1 f tho tle, wl'ite 'SAME AS Sffl:,
<br />'fill, ee
<br />Clion13", lk) check PROPI'llyIN OWN I il 0o,
<br />11L 'FANK OWNE'R INF33RWU10N & ADDRISS BE COh,411,11",`11-,11t-,
<br />Complete all penis ill this section unless all itenis tire the sari-. .4s SECIION tr If thl" samc, write 'SAMEAS S'i'll;, ,wross
<br />this liccticia, Be "'llre to check 'FANK 0WN'T-,,R.S11JP'I'YPI-?,
<br />IV, BOARD OF FQUALIZA110N U91SrORAGEHIE ACCOUNt' NUMBER (Mutz-r 131: lryompumu))
<br />VAItCr your Board of P.qualization (BOE) ITS'I'storage fee accouni llumbcr C"hich is required before Your Permit appliemion
<br />call he procl,,,ased , Registration with the BOF will ensure that \vi!l a quarterly storage fee return irt rcporlim, ihe
<br />SU,'06 16, inills) PCl' g
<br />efflon f due on the number of geilons tiia-'ed 61 fhc. BOY will code person's exclupt flom
<br />paying thesforalge fee So rehitirs will not be sent, li'voll do not hn,,/c cn accounL .,tun bl,,r with the 1301:,' or if ou have any
<br />questicills regarclim, the fee or exemptions, please call tile BOF at ()Pii-323-�)535 or oris e to the 13011 I'lle,foltownij addmss:
<br />board of 1,`C:ue)fiz fion, l.",,tAvironmemal Fees Unit, 1'.0, Box 942879, CA 9-1279-0001,
<br />V, 1IF-FROLEUM 1351' M.NANCIAL RESPONSHILIXfY (MUJr It COMP1JTmD)
<br />Ident6 the ructhod(s) used by the ow-ner and/or cm,c),ator in rnl,cos nn' the Fellcl,ai and State financial responsibility
<br />nequircnwnts. (evaied by any Federal cars State aaeacy art,, txclnpl fri-,mn ll-fis rcquiremew,
<br />VL LEGAL N(YI'I.1q(W110N AN#) BILUNG ADDRE&S
<br />Check ONE BOX for the address that will be used R)r 13i7U U,',(;AL ANT) BILLLNG N0,1114CA110INS.
<br />APPIKAN717 SIUS'1' SIG IN ANL) DNFE11W1, IURM AS IN)II WIED.
<br />INSFRU(7110N FOR'11111 AGhNC 2ES
<br />'I'he County and jodscliction numbers are predetermined and Can bu,�-)Ivwdrled, by calling the Slate Board (916)739-2421. 'I'lle
<br />facifity number may be assigned by the local agency; howevcr, flti,s tT- cru m
<br />trical and cannot contain any
<br />alphabetical, If the local agency prefers the State Board to assign fl-, namb-l% p1case fav e it blank,
<br />11' IS '111E RESPONSIBIUiF LOCAL A
<br />]'Y OF,nC31TNCY '11.!A I' LNiAPFtC'1-`3 '1111l liA'Y 1
<br />('IIXI0 VI I2 U"Y nt
<br />u
<br />ACCURACY OF -11111, INFORMA'DOIN. '111IS 1 PPLICA'110N CAN,,,-ars Y' HE Pl-,',0CllS UJ) 11-1 IlIff DOE ACCOUNI,
<br />NUM13ER IS OUT' IMJ,1tD IM 171F, LOCAL A(;IN(.Y IS FOR 'FITE COMPLE-11ON OF 1111
<br />'LOCAL AGENCY USE ONLY' INFORIMAUON WX AND F(A,, 1 (A31 -10-ANG ONE? FORM "A' AND
<br />ASSOCl/V11-1) FORM -W(i.) 'FO 111E €011, WI ADDRF,'Syi.
<br />I OF (:ALIFORNIA
<br />SEXIM WA7141k RESOURC14S BOARD
<br />C/() smiums.
<br />EWFA PROCESSING C17Nn,.R.
<br />IyO. BOX 527
<br />PARAMOUNF, CA W723
<br />
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