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S Z3 . 0N,S FOR CC)MPLE<'lING DORM "A* : <br /> GENERAL INSi°Tk.UCE[ONS. <br /> L')ISM "A" shall be completed for all h; PI?IZ II ;rT'BB II CHANGE S or any C:`11.IIY/SI!'I; <br /> -I SON Ct %NG <br /> SUBfAr ' ONLY ONE (1) FORM "A' for a i`achity/Site, regardless of the number of hanks localed at: tla. :lite. <br /> T <br /> sl—std be completed by either the PERMIT eXPP11C Amr or the LOC;AI,AGENCY Y CINI)ERC®CCOUND <br /> TANK INSPEGF?I8 <br /> 4. Please type or print clearly all requested information. <br /> .5. Use a hard point writing; instrument, you:are making 3 copies, <br /> { <br /> IOP C?I7 FORM: WAR ONLY CINE TT't3W' <br /> N,La?k an (X) in the box next to the item that bast describes the reason the form is bring,completed, ! <br /> a <br /> 1. FItC.1L.TY/SrfE IWORMAITON &ADDRESS S ( SI'BE C.C) PLUIRD) <br /> i. Record name and address (physical location) of the underground tank(s). <br /> NOTE: address MUST have a valid physical location including city, state, and rip code. <br /> P.O. BOX NUMBERS ART!N(Yr AC(37rABUL <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 approprrate box forTYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) <br /> 4, Check the appropriate box for TYPE OF BUSINESS. <br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked YES <br /> 6. Indicate the NUMBER of TANKS at this SI1.'I?.., <br /> 7. Record the E.P.A. ID# or write "NONE"4h the space provided. <br /> H. PROPERTY OWNER INMRMNnON&ADDRESS(MUST BE CCS I.LBl<71 D) <br /> Complete all items in this section, unless all items are the sante as SECTION 1; if the satire, write 'SAME S SI'I'I,* across <br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box. <br /> 1H. TANK OWNER INFO A'17ON &ADDRJHSS (MUST"BE CC) I4I`I3D) ` <br /> Complete all items in this section, unless all ite rsare the same as SEC CION I. If the same, write *; S SFI7 across <br /> this section. Be sure to check T O . qI. E3 box. <br /> IV. BOARD OF L�.C2C.1 ,17WITON usr S"r() Calx ICE ACCOU BER USF DE c i'rli ) <br /> Enter your,Board of Equalization (BOO UST storage fee account number"which is required before your permit application <br /> can be processed. TCegistrration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the <br /> $9.006 (6 mths) per gallon fee due on the,number of gallons!plaeed in your USTs, The DOE will code persons exempt from <br /> paying the storage fee'so returns will riot be sent,` If you dd not have an account number with the BOBor if you have any, <br /> questions regarding the fee or exemptions, please call the DOE at 916-323-9.555 or write to the 'BOE at thefollowing address: <br /> Board of Equalization, Environmental Pees Unit, P.O. Box 942879, Sacramento, CA 94270-0001. <br /> V. PIiI"ROLEUM UST I CT 'S NS II,I'1"y (MUa E C O r ; ) <br /> Identify the method(s) used by the oAmer and/or operator in meeting the Federal and State financial responsibility <br /> requirements. US"Ts owned by any Federal or State agency are exempt from this requirement. <br /> VI. LEGAL NOrlIFICATION AND BUIING ADDRESS <br /> Check ONE BOX for the address that will be used for DOM LEGALRUJANG NOTIF[CAIWINS. <br /> H ICANIT MUS'(SIGN 1(ND DATF THE FORM AS INDICATED. <br /> INSFRUCITON FOR"I I x LOCAL AGENCIPS <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2427.. The <br /> facility number may be assigned by the local'agency; however, this number must be numerical and cannot contain any <br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. <br /> IT IS THE RESPONSEBUIff OF`IIIA LOCAL AGENCY IITAT INSPEM 11W.FACH117Y TO VE1UFY GIiF. <br /> ACCURACY F THE INK)RMNITON. 11115 APPLIC "1"1ON CANNOT BE PROCESSED 71E DOE ACCOUNT <br /> NUMBER IS NOT F1 ,I.ED IN. 171E; L OC AL AGr9qCY IS RESPONSEBLE FORn1H COMPLEHON OF U113 <br /> 'L O(AL,AGENCY USE ONLY" INFORMNITON BOX AND FOR FORWARDING ONE FORM "A"AND <br /> ASSOCINIED,ICOR 'B'(s)'ro THE FOLLOWING ADDRESS. <br /> SrNI'F OF CALIFORNIA <br /> S I" 'IM WKIER RESOURCEa 4 CONTROL BOARD <br /> c/o Se a <br /> D)VEA P O 7SSING < IT It <br /> P.0) BOX 527 <br /> PARAMOUNT, CA 90723 <br />