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INSTRUC11ONS FOR COMPIXIING 130RM "A"
<br />OHNIFRAL INRIWIC-11ON&
<br />1. One f'ORM "A'shall he compleied for all NEW PERMI'I'S, Pji?R?Wrl'C,11AN(Rtc,' or FA01-rI-Y/Arl,E'
<br />INIk)RM/VIl0N CIIANGEi.
<br />1 SURMn'ONLY ONE (1) IX)RM"A'for a Fecflky/Si�c,, rcgard1esscF flike rlumtm,� ol �e�nk%� !cxc3ted al 0k� &ilc,
<br />1 This fiorm should he completed by either the ��h,(, 1A"-'A-`,;'1tL A iL',,,,,XCY
<br />INSPECTOR.
<br />4, Please Itype or print clearly all requested informaikni,
<br />5� Use a hard point writing instrument, you are making 3 copies-,
<br />'1X)P OF FORNE 'MARK ONLY ONE rIT!W
<br />box next to the itern th'A'e'belst describes the rcasc,,n fie f
<br />I . Mark an (X) in th on,2 "E" "M"
<br />r
<br />L" jkocirdnante and address'64*400cation) of lhe undcr-round Dn0,,�
<br />'Address MUS'.1'have ar--alid physical locarion mduding ""ip co
<br />P.O. BOX NUMBER ARE NOT ACCEPIABLF,
<br />Inclarle nearest cross street and name c�f tfc ol)vvalow
<br />2. Phone number must have an area code, If tile nigho number is' Hic, earnc, in 'pror)""r, bx"ation.
<br />1 Check the appropriato"box forTYPE OF BUSIN."I'SS OWNL�R.Slyfll'(��Y, INDIVIDkJAL, etc,)
<br />4, Check the appropriat6 box OF BLJSINY�SS�
<br />st LAnds� chock the Wx marccd 'YES".
<br />5, If Facility/Site is located on land within an indian re"ervation or crth"er t,�w
<br />6, Indicate the NUMBE'R, of 'IANKS at this SITE,
<br />7. Record the ETA. 11) # or write 'NONE' in 'he spacc provided.
<br />1, Complete all items An this section, unless all itemsare thesatne as SEr,"11ON ii' �he same, write 'SANI[Iil AS S,17YE, across
<br />this section. Be sure to check PROPE.IRIN OWNEWSHIP'l xTT"bok. A
<br />111.1'ANK OWNER INFORIAX1.10N & ADDRINS (MIJS-1'I3R COMP1131',D)
<br />L Complete all heras in this section, unless all items are the same as SECTION If die same, write "SAME AS,, snir
<br />across this section. Be sure to A
<br />IV tX)ARI)OVI�QUAIIZXIIONUVI',T['ORAGIIII�l�A(,X
<br />3
<br />Ft,nter� y1our Board of &,jualization (110F) USN' storage fee account nutuber 'which is requircd before your permit applicatfon,can
<br />+ es "\�Jkegist ration Wille't'houcilgvAll ensuA41aft vou will rcccive a quaaeriy mora'pc lee return in repcirfing tiep $
<br />6 mills) pe'robon fee due on SC�umbe"r of gallons placed in your L ' 'SJ's, The B01:11 ' witl code persons exempt front payi�ng, ific
<br />storage fee so returns will not be sent. If you do not have an account number with the BOEor it' you have any questions
<br />regarding the fee or exemptions, plvise call the BOE� at 916-739-2,582 or write to the IIOE at the following address� Board of
<br />Fklualization. Environmental Fees Unit, P�O� Box 942879, Sacramento, CA 942794001,
<br />V. LEGAL N(X17fr1(.W110N AN13 BILLING ADI)Rfi�,
<br />d for EXY111 NaIM(A1,10N,
<br />L Check ONI� WX for the address that wfll be use z
<br />Ap ON AND DA`111 41 fFff)fW, AS l, (W9,V1`M),
<br />�,M US
<br />IMU'RUCLION AGENCIIN
<br />The county arid jurisdiction numbers, are predetermined and can be obtained by calling the State Board (91t))7-19-2421. The
<br />facility number rnay be assigned by the l(xal agency; however, this numbermust be nometical and cannot contain at, alphabst. If
<br />the local agency prefers the State Board to assign the facility number, please leave it blank,
<br />rr IS 171-F" RESPONS11311,1171'Y OF311F IXXAL AGENCY'lliXf FACIIXFY TO VERIlry THE
<br />A:C
<br />�, (XJRA(,7Y 01l'ITTE INPORMA110N. THIS APPIA(W110N CANNO'r BE PROC37,SSPI'D It, '111E 193H A(X'OUNr
<br />NIJM13ER IS IN. 11W LOCAL AGIN(Y IS RESPONTS1 filli FX)R'111FCOMI'11�110N OF 111E 'J,(`XML
<br />AGFNC'Y USM ONLY" INFORMA17ONDOX AND I -?OR IS)RWARDING ONE FORM 'A' AND ASS -00A110 FORM
<br />'13r(,%)'FO 111E MALOWING ADDR13SS,
<br />'0
<br />KJ
<br />sum 4 iwhM � RNA'
<br />91W17pt W)VIER RESOURCUS WISFROL WARD
<br />c/0 smnflps,
<br />DNI'A PR0C,11SSTNG (.'IWn'!R
<br />P.O. MIX 527
<br />PARAMODW, CA 90M
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