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<br />AN,Si'RUt °1IONI'P il'Ok C:Cs:vii'LL I I ° G FG! AM 'A,
<br />GENURAL INSi`RUIL711OIBES:
<br />1, One F(AI M "A" dial] he Completed for all NEr PE? mn Y, PE'Ruiri' C'EEANGE S or any FAC,11.0`I Y/SI`tT!
<br />Ii FOI-W AIJON CHANGES.
<br />2. SULINIff ONLY ONE (1) FORM "A° for a Facility/ site; re -n clI ss of the number of tatiks located a0i ,.t
<br />3. This foam should be completed by either the 1'1.ItMIT APPI3C°.AN`f or the LOCAL AGENCY UNDE GROLINI-)
<br />4E"lease type or print clearly all rcquesied information,
<br />ation.
<br />r. Line a hard 'point writing instrument, you are making 3 copies.
<br />TOP OF FORM- 'MARK ONLY C71b71: ITENV
<br />e
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />I. IrAC:II.i'I'Y/Srim Ilril }IiMIVIION & ADT2A?Es.�S (musr Bu., C(31LEI'I.i nn)
<br />1. record name and address (physical location.) of the underground tank(s).
<br />NOTE,: Address IM ST have a valid physical location including city, state, and zip code.
<br />P.O. BOX NUMBERS ARE WY AC ° 'tABIJ
<br />Include nearest cross street an.a n,, ,e of the operator.
<br />'_ Phone number rnt.st: have ars area code. night nurnber =ac same, write SAMF'" in proper location
<br />3. Check the appropriate box for TYPE OF 13U, IN'l_>S OWNERSHIP (ex, C,C?RPORA'1' 0N, INDIVIDUAL, cw.)
<br />4. Check the appropriate box for TYPE: OF B Si FSS.
<br />5. If Facility/site is located w #hin an Indian reservation or other Indian trust lands, check the box marked "YE's".
<br />6. indicate the NUMBER of TANKS at this sir,',.
<br />7. Record the E Y.A. 11:) # or wT� to "NONE" in the space provided.
<br />EI. PRdII'E I -Y O NV'. INFORMATION & 1A DRESS s -F BE C OMPIJ-:- D)
<br />Complete all items in this section, unless all items are the same as SE( -TION I; if the sante, write 'SAME. AS SFIV.* across
<br />this section. Be sure to check PkOPERTY OWNERSHIP TYPEi box,
<br />III. TANK OWNER INIORMJV11C)N & ADDRILSS (M[JSi' BE COMPI, QVD)
<br />complete all items in this section, unless all items are tile sante as SECTIO 1; If the same, write 7 riCF AS ST"1'E- acro"."
<br />this section. Be sure to check "E"",Tit. C3 0 E 1 TYPE'S box.
<br />IAS. BOARD OF ErQUA3.IZ,ATION U',' IF STORAGE FEE? 1AC'C:C)t Nrl' L1MBE3R (MUSS' BE C;OMPI.i3'n'13)
<br />Enter your Board of Equalization (I30E) ?.,13-17 storage fee account number which is required before your permit <sp{rlia:.atic:n
<br />can be processed. Registration. with the BOE, will ensure that you will receive a quarterly storage fee return is reporting the
<br />$0.006 (6 mills) per gallon fee due on the number of gallons placed in your US'i's. The BOF will code persons exempt lton
<br />paying the storage fee so returns will not be sent, if you do not have an account number with the BOE' or if you have any
<br />questions regarding the fee or exemptions, please call the BOE: at 916-323-9555 or write to the BOE at the following address:
<br />Board of Equalization, Environmental fees Unit, P,O, Box 9421379, Sacramento, CA 94279-6001.
<br />v. PE?E'IRCII.,F?EItm u,,;r FiNANcw. RE-sPCINsiBiluri'Y (muss, BE C'C3mE'I;Em-.1i)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USI"s oumed by any Federal or State agency are exempt from this requirement.
<br />VI. I.,EGAE, NC `J1FI( "I7ON AND BII.L,ING ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH E.F, ;A1, LAND E IUING N4aITFICAI1C3,NS.
<br />APPLICA i° MUST SIGN AND DKfF T11E FORM AS INDICIATED.
<br />INS'I RLK 11ON FOR111E LOCAL tAGENC,`I a
<br />'Fire county and jurisdiction ,numbers are predetermined and can be obtained by calling the State Board (916)739-242:1. 'Phe
<br />facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any
<br />alphabetical, It the local agency prefers the state Board to assign the facility number, please leave it blank.
<br />CI` IS 'n IE RF-SPONS BJLrE'Y OF 711F LOCAL AGENCY '111AT INSPEi(71I; 111E3 FACE1JTY `11O WMIFY 1111 .
<br />ACCURACY OF TI3E INFO t .T1G.N,'PIUS APPLI A"1`10N CANNOT BE PROCESSED IF '-11--111 F301-1 AC " EJI` F
<br />NLTMB[4',R IS NOT FIE.I.,Fit IN. '[III, LOCAL AGENCY IS REAiE"ONSIBIT FOR 'I EIa C",C)MPLITTION O 'IlIli
<br />*LOCM, AGENCY USE,' ONI.tet' LNFORMNIION BOX AND FOR ]IRWARDING ONE, FORM "A" AND
<br />A.`iSOC"Its TiI3 FORM "B-(s)TO THE OI.,I OWJNG ADDRE:.SS.
<br />KIWI`H OF CALIFORNIA
<br />SE"ft" I? KJ`EIR RESOURCES COWROL II)ARD
<br />C/O S. .n a s.
<br />'I )VY A PROCESSING C^E?NIER
<br />P.O, I3OX 527
<br />PARAMOUMF, CA 90723
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