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<br /> INS-J'R1.J `11ONS FOR C0MPLU7I1*RM-A-
<br /> GENERAL IN,'6;l'RUCnONS_
<br /> 1, One FORM "A"shall be completed for all NF'W 1pi.amns,PERM1171'(11ANG17-S or any FAClury/srim
<br /> INFORMN17ION CHANGIT-S.
<br /> 2, SUBMTr ONLY ONE,(1)FORM"A'for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3, This form should be completed by either the P17RMrF APPIICANT or the LOCAL AGENCY UNDERGROUNDTANK
<br /> INSPM, 'OR. 1,
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing;instrument,you are making 3 copies.
<br /> TOP Of?FORM: 'MARK ONLY ONE rIEM'
<br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> i. FAciury/sirm INFORMA'116N&" ADDRESS(mu,, r BF.wiviiiimig))
<br /> 1. Record name and address(ptiysical location)of the underground tank(s).
<br /> N(YFE: Address MUq'have a valid physical location including city,state, and zip code.
<br /> P.O.BOX NUMBERARE N01ACCEPTABI-1-1
<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 "SA14S1:11' in proper Wation.
<br /> 3. Check the appropriate box for TYPI-i,OF BUSINESS OWNERSHIP(ex. CORPORATION, INDIVII)IL"AL,etc)
<br /> 4. Check the appropriate box forTYPE OF BUSINESS.
<br /> 5. If Facility/Site is lo&ated.on land within an indian reservation or other indiin trust lands,check the box marked "YES".
<br /> G. Indicate the NUMBER ofTANKS at this SITE.
<br /> 7. Record the E.P.A. 11) ---1 or write '.'°ONE" in the space provided.
<br /> M PROPEKI'Y OWNER INFORMA-110N&ADDRESS(muss Biz COMPI,Iqlm)
<br /> 1. Complete all iterns in ibis section, unless all items are the same as S[--,(-FI0N 1; if the same,write"SAME AS SrJ1!*across
<br /> this section. Be sure tc•check PROPERTY OWNFRSHIPTYPE box.
<br /> JILTANK OWNER INFORMA-1`10N&ADDRESS(MUSIAW", )MPLK11d))
<br /> 1, Cbmplcte all items in this section, unless all items are the same as SUCTION 1, If the same,write "SAME AS SrMl'
<br /> across this section. Be sure to checkTANK OWNElkSHIPTYPE box.
<br /> IV BOARD OF UQUALIZK11ON U,1 1'S'T'ORAGE FIJI'ACCOuNr NUMBER(MUS` BE CX)MPlJ?1Tj))'
<br /> Fater Your Board of Equalicaiion (S3OE') USS'storage fee account number which is required before your permit application can
<br /> be processed. Registration with the BOE%vi]] ensure that you will receive a quarterly storage fee return in-reporting the soof%
<br /> (6 mills)per gallon fee due on,the number of gallons,placed in your U91's. The BOE wrill code persons exempt from payripa,the
<br /> storage fee so returns wiH not heserlL rt
<br /> do not-bave an number with the 11011,or if you heave any Ocstions
<br /> regarding the fee or cxcrnpicasplease cL11 the 1301at 916-739-2582 or write to the BOF at the following address: Board of
<br /> Equalization,Environmental Foes Unit, P.O. Box 942970,Sacramento, CA 94279-0001.
<br /> V 11XIAL NC'HFICA7110N AND BILLING ADDRESS
<br /> 1. Check ONE BOX for the address that will be used for BOTH 11:GAL AND B111,ING NOTIFICA'nONS,
<br /> APP11CAW MUSTr SIGN AND IWtT*1'111F FORM AS INDI(Ana).
<br /> INS-FRIX-17ION FOR.'119 LOCAL AGENCIES
<br /> The county and jurisdiction ntrnhers are predetermined and can be obtained by calling the State Board (910)739-2421. The
<br /> facility number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the Stile Board to assign the facility number,please leave it blank.
<br /> rr 1ST11F RESPOMSIBILM OF'rim I"AL Aomcy nwr wsmcrsuip-mcnxry,ro wRivy,n][E
<br /> ACCRA(A OF'111E INFORMA'1710N. 1111S APPIjcxnON CANN(Yr BE PROCT-SSED IF'1111!BOH ACCOUNT
<br /> , 'C-t-WPLFTION OFTHE*LOCAL
<br /> S
<br /> NU? iIsS'j�kyr iquiu)IN. '1111K LOCAL AGENCY IS RE-SPONSIBLE FOR 1111,1
<br /> AGENC'Y U%M ONLY"INFORMA71'10N BOX AND F()R FORWARDING ONE FORM"A'AND ASSOCIA7110 FORM
<br /> -HIE F011,0WING ADL)RH-S&
<br /> ST/01K OF CAIJFORNIA
<br /> S1 KI �WY1MR. SA)UCESO17, 1,BARD
<br /> ('/()S.W.11�I P'&
<br /> I)XI'A PROC11,SSING, CEMIE'R
<br /> P.O.BOX 527
<br /> PA.RAMOI JNT,CA%M3
<br />
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