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INSMUMONS FOR COMPLIK-17ING FORM W
<br /> Gf-tNERAL INS-I'RUMONS:
<br /> 1, One FORM "A' shall be completed for all NIM PERMITS, PERWI'MANGEN orattv FAC11'rrypsm,
<br /> INI1)R.M,S:n0N CHANGES.
<br /> 2, SIRMI'ONLY ONE (l) FORM for a Facility/Sile, of the number of lankh Hie
<br /> 1, Thi's form should be connole,,cd bv either the PEM-MI'T A11PLICANFor thy. LOCAL AGENCY U-NDITIGROUND
<br /> TANK,,NSPECTOR.
<br /> 4, Pfcase type or print clearly all requested information,
<br /> 5. Use a hard point writing instrounent, yon are making 3 cofts,
<br /> TOP OF FORM: 'MARK ONLY 0,NE11Ttlol-
<br /> ,jark an )"i tire box neta"11i The itoun that bey describes the reason the f`o "Is, bentgtconlptqleda
<br /> L ItAiIITiYfS 7i K)RIWAMON& ADDRI
<br /> (MIJ';r BE,COMPLI-17ED)
<br /> L Record name and address (play-sical location) of the underground 1,anl,(s).
<br /> NOJT�: Address MUST have a valid physical location including city, state, and zip node.
<br /> P.OBOX NUMMIRS ARE WYI'A(XMVrABM-
<br /> Include nearest cross street and name of the operator,
<br /> 1 Phone,fbinber must have,an area code, If the night number is the same, write "SANNIE' in proper location,
<br /> 3, Cheek tile appropriate bd'for TYPE OF'BU SINESS OWN113RSHIP (ex. CORK)RA110N. lNL)IVlI`)UAJ-
<br /> 4h Check the appropriate box for 1-YPI,,,' OF BUSINESS.
<br /> If Facility/Site is located v6tbul an Indian 'reservation or other Indian trust lands, check the box nia6cd "YES",
<br /> 6- Indicate the NUMBER of TANKS at this SITE,
<br /> 7. Record the E,PI A. ID # or write 'NONE" in the space pf6vtdM,
<br /> It. PROPEWIT OWNER IWORMNIMION& ADDRESS (MUS17 BE,-C-0MKJi`1 I111)
<br /> Complete all items in this section, unless all items are the same as SEcno-.� 1, if the same, write 'SAME, AS SFIV"
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box,
<br /> Ill. 'I'AINK OWNEI-1 INFORMNnON &AD RK,
<br /> (MUS�1'Pp4 COMPLU-1m))
<br /> I , 4
<br /> Complete all items in this section, unless all items are the same as SE(THON I. If the same, write�',4,vWli AS SrIV,' racrc ss
<br /> this section. Be sure to check TANK 0VMFqZS1I1P TYPE box,
<br /> ON USt�Kff')RAPW FEE ACCOuNr NUMBER(MUSS BE' (X)MPJ.J--1ff 0)
<br /> IV, ROAR4 01!EQUAWAII
<br /> E,nter your Board of Equalization (BOE) UST storage. fee account number which is required before your permit applicaGost
<br /> can be processed, Registration with the BOE will ensure that you will receive a quarterly storage fee return in rcporfim, the
<br /> 4t}.006 (6 (sills) per gallon fee due on the number of gallons placed in your U51's. "I re BO—E will.fode perAxis cwmpt fron"
<br /> do not jlill� aw atebunt`nu0hb0A I It
<br /> paying the storage fee so"ret riffs VAll'(ult bx''sent. �It you with t AOEI or if yotht,4 ,",iA,
<br /> quesdons ,regarding the fee or exemptions, please call the BOE at 91.6-323-9555 or write to the 110E at the followitlo
<br /> Board of IzIonflization, Environmental Fees Unit, P.0-Box 942879, Sacramento, CA 94279-0001,
<br /> V. 1`13,,MQIJ��LJJM U!;f 11MANC2AL,R1.,,$P,0N. .=HXJ-Y f1LJSF BE Carr MPLU-11.1))
<br /> Identify the method(s) used by the on-ner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USFs owned by any Federal or State agency are exellipt from this requirement.
<br /> VL LEGAL MY11MAHON AND BITLING ADDRIM
<br /> Check ONE BOX for the address that will be used for Wril 11XIAL AND B111INGY NOMMCKIIONS,
<br /> APPLi(ANr musir ICI ,A. DAT. E TfIll FORM AS MKW119),
<br /> IN'TMUMON FOR it LOCAL ACs ENCIMS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (910)734)-2421, The,
<br /> facility number may lie 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 facilitypumber, please leave it blank,
<br /> rr is a7mtumlOWSIBUXIT 017 11111,LOCAL AGUINCY TIIIVI'INSPECTS WETACIM'.Y TO VIDUFY'171111
<br /> ACCURACY OF'111E INFORMN110M TIMS APPLICATION NN( r'B13VROC-8SSED EF"m DOE
<br /> NT f MBFR IS;N(Yr Fill 11-1.) IN. T1 H-t LO(AL GIHNCY IS K POS 3I U IlOR nIli compi jq'ION OF 171
<br /> 'LOCAL AGENCY USE-ONLY" INIA � FOR il6RiX-i&NG ONE 110AM"A-AND
<br /> ASSOCINI'M FORM W(s)TO TFIF FOMOWING ADDRI3,-%.
<br /> SM'113 OF CYtHFORNIA
<br /> 'WATEM R1
<br /> MITM RENOUR(TS CT)NIMM, )A
<br /> c/0 5.V;1:1J,--P,.S.
<br /> DVr-A PROCE-SSING (JiMMR
<br /> F,O, BOX 527
<br /> I'ARAMOUNF, CA 90723
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