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INSTRUCTIONS FOR COMPLLFIING MRM 'A'
<br /> GENERAL. INS-I'RUC`11ONS:
<br /> L One FOIC11 "A" shall be completed for all NEW PERMYIN, PERMIT CIIANGES or any 1-*ACIIri-Y/SI'1'1,"
<br /> INFORMYVIION CHANGES.
<br /> 2. SUBMr1'0NLY ONE (1) FORM "A* for a Facility/Site, regardless of the number of tanks located at tile "'itc.
<br /> 3. '11is form 'could be completed by either the PERMIT APPI1CANT or the LOCAL AGENCY LJNDI;RGIZOUND
<br /> 4. Pl Print requested information,
<br /> 5. Use a rvo oo�int writing instrument,you are making 3 copies.
<br /> TOP CTI? RIA: 0T,-I,Y ONE
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> - 3 LE-110)
<br /> L FAOIrl'Y/,Srl t L B94ORMNIION&ADDRESS (MUST BE COMP
<br /> 1. Record name and address (physical location) of the underground lank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX NUMBERS ARE N(T;'ACC1WABLE.
<br /> Include nearest cross, street and >�ie of the operator.
<br /> 1 Phone number must have an area code. the night number is the same, write "SAME" in proper location,
<br /> 3. Check the appropriate box for TYPE OF i"USENESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL. etc.)
<br /> 4. Check the appropriate box for TYPE OF iil,:,SJNTESS.
<br /> 5. If Facility/Site is located within an Indian ==-mivation or other Indian trust lands, check the box marked "YES".
<br /> 6. Indicate the NUMBER of TANKS at this
<br /> 7. Record the E.P.A. ID # or write "NONE"' in the space provided.
<br /> EL PROPERTY OWNER INFORMNITON & ADDRESS (MUST BE COMPLETED)
<br /> Con�plcte all items in this section, Ojies, '', items are the same as SECTION 1; if the same, write "S'AME".AS sri*E" across
<br /> ihk src!1,,n He sure to check PR011'1 k(Y OWNERSHIP TYPE box,
<br /> 10 1ANk ENI-0&i` ?'V1TON & ADDICT-ss (MUST BE COMPLLMT D)
<br /> Compicto all items in this section, unless P0 itcns ars the same as SECTION 1; If the same, write *SAME AS S11137
<br /> this sec0-,n. Be sure to check TANK OVVNs"R'Stflll V'ffF hox.
<br /> IV. BOARD OF EQUALIZATION UST ORAGE Fl,,"l ACCOUNT NUMBER(MUST BE cor"11-H-33)
<br /> Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the DOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. Tile BOE 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 B(V,or if,you have any
<br /> questions regarding the fee or exemptions, please call the DOE at 916-32.3-9555 or write to the BOE'af the following addrcss:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001.
<br /> V. IT"I'ROLEUM UST FINAN10AL RPSPONSIBIL=(MUST BE COMPIHIED)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> i-,.-quirements. USTs owned by any Fedcril s)r State agency are exempt from this requirement.
<br /> VI, LEGAL NO7IUqC11lTON AND Blill—ING AIX-)RESS
<br /> Check ONE BOX for the address, that will be used for BOTH 1,1XIAL AND BUJING N(Y]IFICA'11ONS.
<br /> %.JTlJCANT MUST SIGN AND DNFE'111F FORM AS INDICATED.
<br /> INNS fRU CON FOR TIIE LOCAL AGENCIES
<br /> The county and jurisdiction numbers 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 number must be numerical and cannot contain any
<br /> a1pbabeticaL If the prefers the State'Board to assign the facility number, please leave it blank.
<br /> W 1 m 1 "J THAT INSPF(7J-,`S'nil! FACILrff To VIS, w-y Tw-�
<br /> OF illi�
<br /> IS Nffl' k I" tP"- AGENCY IS RENPONSIBLE FOR 111F,COMPLY-FION Ole'nll,"
<br /> 1110('Ai- "�61WCY Wiil CRf' SAN PDX AND FOR FORWARDING ONE FORM "A" AND
<br /> AS,S0(';',A:J'V'D i�fi!NM H-I-,P'OcA iDWlN1',f A DIJRFSS
<br /> &A'A I P OF CAT FORMA
<br /> WAT' RVI OURCES CONFROL 133OARD
<br /> C/0
<br /> PARM401,'N1', CN '-,,')723
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