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` 4 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> s�rrre Ti�P^`.` A <br /> FORM `A': wY h�a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION ., <br /> . f <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "A" shall be completed for all NEW PERMITS, PERMIT CHANGES or any FACILITY/SITE INFORMATION <br /> CHANGES. <br /> 2. SUBMIT 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 PERMIT APPLICANT, or the LOCAL.AGENCY UND'ERGROUNDTANK INSPECTOR. <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 ITEM" <br /> 1. Mark an(X)in the box next to the item that best describes the reason the form is being completed. <br /> 1.FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 1. Record name and address(physical location)of the underground tank(s). <br /> NOTE: Address MUST have a valid physical location including city,state,and zip code. <br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE. <br /> Include nearest cross street and care of address information if appropriate. <br /> 2. Check the appropriate box for TYPE OF BUSINESS. <br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP.(ex.CORPORATION, INDIVIDUAL,etc.) <br /> 4. If Facitity/Site is located on land within an indian reservation or other Indian trust lands, check the box marked "YES". <br /> 5. Phone number must have an area code. If the night number is the same,write"SAME"in proper location. <br /> 6. Record the E.P.A.ID#or write"NONE"in the space provided. <br /> 7. Indicate the NUMBER of TANKS at this SITE. <br />.j <br /> II.PROPERTY OWNER INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 1. Complete all items in this section, unless all items are the same as SECTION 1; If the same, write"SAME AS SITE"across this <br /> section. Be sure to check PROPERTY OWNERSHIP TYPE box. <br /> 111.TANK OWNER INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 1. Complete all items in this section, unless all items are the same as SECTION 1; If the same, write"SAME AS SITE"across this section. <br /> Be sure to check TANK OWNERSHIP TYPE box. <br /> t <br /> IV.LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 1. Check ONE BOX for the address that will be used for BOTH LEGAL and BILLING NOTIFICATIONS. <br /> E Applicant must sign and date form as Indicated. <br /> IT IS THE RESPONSIBLITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE:ACCURACY OF THE <br /> INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE-COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION <br /> BOX AND FOR FORWARDING ONE FARM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS: <br /> i <br /> STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />