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<br />LN,%-rRU(','I10N1'S FOR COMPLEJING FORM 'A'
<br />GENERAL INS tat ]TO S.
<br />1, One FOLit1 "A" shalt be completed for all NAV VERMYn, I'ERmn" ?*IGE-S or any FACIl TY/SITE
<br />INFORMNITON CHANGE
<br />2, S'ul i .T ONLY CINE(1) FO �A' for a LacslityJStc, regardless of the number ofranks lucaled at tile.
<br />3, This form should be co pteteu by either the I']4ZM "1" PI`1.1Cz'imr (it the LOCAL AGENCY C7N17ER 6iC# UND
<br />TANK INSPEOTY)R.
<br />4. Please type or print clearly all requested informalavan.
<br />5. Use a hard point writing instrument, you are making 3 copies,
<br />TOP OF ' 'C) 'MARK ONLY ONT1 TY04"
<br />Marl, an (X) in the box next to the item that best describes tlae reason the form is being comlttexed,
<br />I. CILII'Y /SI LE, IWORMNITON & ADI &S (MUST' ISLE O . L I )
<br />1, ILecorcl name and address (physical location) of the underground tam(s).
<br />WIT': Address NAUST have, a valid physical location including city, state, and zip :odea
<br />.Ci. BOX NUMBPRS ARE t lYr L.
<br />Include nearest crass street and sante of the operator.
<br />1 Phone number must have an area code, If the Tright ninttber is the same, write "SAME" in proper location.
<br />3, Check ghe appropriate box for TYPES 0"I" BUSINT.' SS C WNEHRSI1f e (ex, {:'C1RF'OR 'It0N, INI)IVII';tJ.' L tie)
<br />4, Check the appropriate box for I-VIII]T SE\�IaSS,
<br />5. If Facility/Sita is located within an Indian resetnration or ;ttlser radian utast; lands, check the box marked ES".
<br />ti. Indicate the NUMBER of TANKS at this STFE.
<br />f i.
<br />7, Record the I;T.A, ID # or wide "NONE" in the space provided.
<br />H. 1'12<3T'E I`Y OWNER INIAORMNITON & ADI)RRS pvruSF BE COMPL 1'fill) ,
<br />Complete all items in this section, unless all items are the same as SP,C rl(.) v 1; if the sa€tee, write 'SAME, S SFIIE° across
<br />this section. Besere to check PROPERTY OWNERSHIP TYPE, box,
<br />1U. TANK OWNER I IORM/ 1"ION S rIL5DRT- S (MUSI` HE C°C:l PLE-111))
<br />Complete all items in this Section, urslcss all items arra the sante as S ( 110 I; If the s<aattc, write: 'SAME AS SI'tr " across
<br />this sectiom Be sure to check TANK 0 HILI` TYPE box,
<br />IV. BOARD OF EQUAUMPION LIST SYORAGE 11194, AC;C'CILE I` Nig ER sr BF, ampt.pni-m)"
<br />Pinter your Board of Equalization (BOE) LTI51' storage fee account numbar which is required before your Ire.rmit applic:.ition
<br />can be prcwcssed. Registration with the BOE will ensure That you will receive a quarterly storage fee return in reporting the
<br />$0.006 (6 mills) per gallon fee due on the as€smber of gallon-, placed in your USI's. The BOBwill code persons exempt £voile
<br />paying the storage fee so returns w,;a not be seni, If you do not have an account number with the 1I0E or if you have any
<br />questions regarding the fee or exemptions, plea ,all the BOB at 916-323-9555 or write to the BOE at the following address:
<br />Board of Equalization, Environ eata al Fees Unit, P,O, Box 942879, Sacramento, C".r� 94279-0001,
<br />PBribca.,Bum u,5r Rlmytcw, REspordsmillmy (fv1LI T III; co L u rEI
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USE; oomed by any Federal or State agency are exempt front this "requirement,
<br />VI. LFG L N,(YlTn(:KITON ANDhI UNCI II,-)LASS
<br />Check TNF BOX for the address that will be used. for IIC11Id'1 .:AND BICJ11FTC' :I"1ONS.
<br />LIC T mut S r SIGN AND Nt'L? "IrI'.LE FORM AS I 'IC 119),
<br />IP3 nFRIK ION FOR THE LOCAL AGENCIRS
<br />The county incl jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. "rice
<br />facility number may be assigned by the iocal agency; however, this number must be numerical and cannot contain any
<br />alphabetical, if the local agency prefers the; StateBoard to assign the facility number, please leave it blank.
<br />I'1' IS 77111 RINK)IN!,911ILT11Y OF TIT E LOCAL AGENCTY THAT INSPFC717S r'1 1r F C WIY 110 VEPAry THE
<br />. CC C.' OF '171 aCI .. ' N, '1 S tllrrL,ICNfIO CI'I' II ROC S.SED % 'IIIE - )err
<br />NUMBER IS N0`J' F11J,ED IN, 'ITIF LC (AL ill? S t S ONS :I L E FOR Tiffil CCIMI'LI I101d OF 7111i
<br />"LO(AL AGENOYUSE' ONLY' INFORMATION BOX AND FOR PORWARDING O 3 FORM 'A' AND
<br />ASSOCINITO FO ' '(s) '1 'I`II F(HLO I CI ADDRESS.
<br />Oil CALIFORNLA
<br />I °1"1 4 VIA711iR RESOURCESa CIL DOARD
<br />C/o S TLEP S„
<br />POC BOX 52.7
<br />P I"ICI 'I`, % g�
<br />911723
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