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<br />£ £ p �IN'E i""', u ,.<
<br />, ..a , ,. ._.,., l ,. z „ .,.. ,., ,...,
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<br />,l,Fc, £ _`, t �,. tier ' t r x .It ?f �° �" ,,I` A>�.. €�, .,. £� 2 a,.+t..
<br />3. �� int, i�rrr si.�,� k„ ��. �ea.r.� fNt�� , £ „,���a,. the l � s . �,r s.i =3a �� �
<br />TANK INS11-FICTOR,
<br />all rcoucsgcd
<br />t...: r-' W,. [.. t;,-; are nmoong 3
<br />- f
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<br />1",m..:it.;,, > i!S ITT INF'ORAIMIO &A.#.s R3,,,,',Rs (Multi I,t::
<br />L Record name and address (ph yslzallocation) of the cir`c9„,g,atin
<br />cihC"',rtevn3 physical fo.an a,eicac, €,. ,ENOI Ar t uei
<br />Ia£.asc,., nca.c.ut cross street and naive of tae qp. rat.rt
<br />Phone number maisi have an atea code, If ttre nifffit nuanbcr is the same, a m,o oet }t7..i7 Yi12;,
<br />5. Check thy.: , i pf i r o r, r i a t e e ox for Ts' E OF BIL'SINI S r I AT N I :=tSr,I, c x ,Rsg, ttr>.e
<br />Chock ilio pox for f s'P 01" BUSINESS,
<br />5, If /.i " _c;_i,v ,` an Indull, re >u m c , £ ,.., ,c t .. <i .,.x m "k.,..,
<br />Record
<br />It. IktmCIl'I°.WI F' OWNER tl.f ORMS,31ON A ADIMHSl s OVI L.,r> {sett. f�irik ti;
<br />Complete all items, in this section,unless all ftirE„ a,3., the s.iF, . S£,t,. bEI�', a ,as,4, wHtc 1SAME, AS - <scsss,
<br />this section, Be s i; c, to chc cl PROPI",IC'I'Y OWNF'/%; lJ1I1 1 s , _
<br />III. TANK OWNER I irOR TIONFFIIRR—olI MU,ll'BE CTMIS"a.ts"'.I 1' )I ,
<br />C,<.~rsplate all at.:ras in this srci;t>i"t, unfcss all steits are t=e ;a £,;u ww St ';"FI=,�. 1. If „ice ,<..._r ,£,s+ie' "SAME AS STt`t"
<br />this seclion. Be svre to ghee 'FA'FANK CI Fs FII I'YP ? box.
<br />Irl, 130AR13 017 UALIZA'110us-r 'I CII? ITE AC,C CICs"NI' NUM[BUR, UR, ? a St' IIII ComPT ° ? )
<br />Enter your Board of a.'.ixjualizatii3n (BOL',) USTstorage fae accou.=;t ttu£3.f cv e, re€ uin"d f"et.orc Four permit al
<br />;:ar, be 7'.iYCii;eseed, Registration with the Bt.)E ivill 4usure thatc,,oi� t recorve a qu,, .tc i.y s?.oragc fee return in it,.tlo'r1in" th'-,
<br />rf).f) 6 (6 mi[ls) per gallon fee brie on the number cif gallorw r,lace f in your U IM, he IICsi,i will code parsons cx€,mpt from
<br />:ayin- the storage Fee so :returns will itch be seta. If you ;o nor have an arcow tt r;umher xvisli the 1301,' or if' you have any
<br />questions rel,arding, the fee or exemptions, }tease call the 1301^; sst 9'16-373-•J'1555 -•?*:*5 or wnc° to ilia BOE at the follovii=f:
<br />Poard of € luatfratnn, Ltiri€on icnial Fps Unit, P,O, I,c:s942-`-',7`),
<br />° ,i...�3 .�£>i , t� � �.'.i-•: n_
<br />V. PEI R;it, °U CSS"1° FINANCIAL WS " tNSttttIXI n"i"l,
<br />ItTsaaall;y the meth . f(s) used by the carne' and/or ontra for i,£ Yeduzil. and t satin Pi,ian �d resperrasai iiity
<br />requiremems, ems. TS -l's ovae' 1�y ane Federal €, r Sua , "n _V,
<br />Check ONE O for the saddle that at, be used for 1317111 , .-c' 1A01, Ar,41,11 BILL1114(i INKY11111(WIVIONS,
<br />APPLICANT must' SICHN AND DATE ME FORM AS I DT( 'IT,R
<br />I "ttt'tIOCTIO FOR '1131, WCAL A 04CHNI
<br />The county and Iii,.Sd.rttron =s.o.ztfses°s are Cozeoa*nrrLiined and .� .ffic "`,tatY BU-aand3ct'f5�, „i �tL. "I°Fe
<br />facility number ti,t be as igned by t£ie" Isa.£I atelxc,, b„is,cYe„i. „ , ;.,,£ ,.r .. ,, t€= £ ujr,,it c°t rt_.1 .asiy
<br />atl;habetecal, If the local agency profers flie State Board to ,, , ..,;: 1-H, h,avc it blank,
<br />II` Is THE RESPONNSIBUXEY OFr'F II° t,C"IC L A alE'Nl; t,.. ,: ,r.` r' 3:;C, P' .1111, VAICIIALPPY TCI VFEI "I`IIt
<br />A(X7URACY OF '1`II.I_ I I' )IMMION, `I"IIIS AI'H IC.PO II, . (1AN Rei O is 111%01,7'` ,'SSH` II° 'I'IIII I II° C,C;OUIN'I'
<br />NUMBER IS N(YF F111,10 I: . 'ITIE L0QXL AGENCY,IS RUS e NIBLI , "0'C el E C:OMPLI ION Clic` `ITS
<br />'LOCAL AGEINCY USE ONLY' I:NFORMA13O WX AND Ii )R , :"s,dssI,IIC:tIINO ONE FORM 'A' AND
<br />diS,SCI(✓I11"['I?iS Ik)Ie "W(s) TO '11IF" : s`CiLL INc; F"x ilFtl='�S,
<br />tTFAI ?CIF CALIFORNIA
<br />ImIWI , WNFEIC tII:IISCIt,II.(TS (70IT' C)t”, cIt)At
<br />c/osmxmrs-
<br />PROCESSING
<br />" P.O. 13OX 527
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