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<br /> 11N1S 1",'�'C 110NS FOR COMPLVIING FORM "A"
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<br /> 60N,-' "ill..INSPILUC"IONS;
<br /> 1. One FORM "Al* shall be completed for all NEW PERMTI-S, PERMrl'(:MANGES or any FACI1,11'YrtSrIV,.
<br /> INFORMAI'IO)N CHANGI:IS.
<br /> 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless oi" the number of tangs locmed it th•
<br /> 3. This form should be completed by either the PERMIT APPLIC:AN•I'or the LOCAL AGENt.'Y 1>NI:)I.12{;C.t)tJ RC 1
<br /> "TANK ENSPEC`I'OR.
<br /> Please type or print clearly all requested information.
<br /> 5. Use a hard point writing; instrument, you are making 3 copies.
<br /> '.IOP OF MRM-- "MART{ ONLY ONI3 rI"E:`M'
<br /> Mark an (X) in the box next to the item that best describes tete reason`t16 £ordi is bein`g tbnnpletc;d.
<br /> I. l> f'It;ITfSI"I l =O1Mt"TUO)N & AI7I)I15(A3J1�I3 3COMPLIiI7I'Jt) / t
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<br /> 1. . Record namo and address,(physiN,lVeation) of the underground tank(s).
<br /> NOTE, Adcifess MUST hhvd=a Jandl physical location including-city, state, and rip code.
<br /> P.O. BOX NUMI31IRS ARE N(7r AC'CZWADI.J,
<br /> Include nearest cross street and name of the operator.,
<br /> 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location,
<br /> 3. Check the appropriator box for TYPE OF BUSINESS OWNERSH- 111(ex. CORPO:IRAIION, INDIVIDUAL, cle.)
<br /> 4. Check the appropffate--hQx for TYPE OF BUSINESS. ,}k,
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust: lands, check the box marked "YT?'W.
<br /> G. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A. I1:) # or write "NONE" in the space provided.
<br /> U. PROPERTY OWNER INFO) TION& ADDRESS (MUST BE C OMPLVtT0) `.
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<br /> Complete all items in this section, unless all items are the same as SEC'T'ION 1; if the same, write "SAME;ASAITEI" across
<br /> this section. Be sure to check PROPER'I'Y OWNERSHIP TYPE box. t
<br /> III. 'TANK OWNER INFORNIX11ON &ADDRESS (MQ,13T BE CO I :: 3))
<br /> Complete all items in this section, unless all items are the same as SECT ON :1; If the same, write "'+ALAS SIII" across
<br /> this section. Be sure to check TANK IIy'a'NT ILM1111=IYPH box.
<br /> TV. BOARD OAF FOUAL:I Al ON USI'SI'OkAt Ff VEE.ACCOUNT NUMBER(Musr BE C:OMPI1T110;1
<br /> Enter your Board of 1::squalization (BOE) USI'storage fee account number which is required before'yotu•permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage ee return in reporting the
<br /> SO.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE wig code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with tete BOE or if you have any
<br /> questions regarding; (lie fee or exemptions, please call the BOE at 916-323-9555 or write to the 130E at the following address:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0000
<br /> V. P1-q'ROLI:UM USI'FLNANC"IAL RESPONSII3lury (MUST BE COMPII?11a)) �,+
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and Slate financial responsibility
<br /> requirements. US'I's owned by any federal or State agency are exempt from this requirement.
<br /> VL LEGAL NCY11MC:ATION AND BII.IING ADDRESS
<br /> Check ONE BOX for the address that will be used for I3O11I LEGAL AND 3III . G NOTWICNIIONS.
<br /> APP.IIC.AW MUST SIGN AND DATE 11 IE FORM AS INDIC,'AI1 113,
<br /> INSIRU(:iLON FOR'11W LOCAL AG NC:IES
<br /> The: county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (£916)739-2411. `llic
<br /> facility number may be assigned by the local agency; however,this.number must be numerical and cannot contain anc
<br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> sT' I--S`1111: RESPrf 'N113,II1I""' OF I7HI Iiiat"`AL .fit%1:�;'tiO"Y'I'ISt�,'1'I'.�aS.l�T:s`C'I:S`I'TI1? FAC;II-HY TO WRIlly I71I1.
<br /> ACCURACY 01111W INFORMA11ON, "11115 APPLICATION NNOT`F BE PROCESSED IF'EI-tII BOL= A('COUN`T°
<br /> NU IS N(fl' 01I,1iI7 IN, '177 LOCAL AG124CY IS RESPONSII31 14 FOIL TI1IS COMPLE-11ON OF"1HE
<br /> *LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE:14ORM "A"ANI)
<br /> AS.SOCTAWD FORM "i3"(s)TO I'IIF"FOLLOWING; ADDRESS.
<br /> SEK1111 OF (:ALEFORNIA.
<br /> M IV WAIIIR RESOURCES CONTROL BOARD
<br /> C/O S.W_is
<br /> pd. DATA PROCIaSSIN(i (X -it,
<br /> P,(. BOX 527
<br /> PARAMOUNT', CA 90723
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