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INSTRUCTIONS FOR COMPLETING FORM 'A" GENERAL.INSTRUCTIONS L One FORM'V,A" shn'I be completed for all NEW PERMITS, PERMLI'CHANGES or any FACIIIIY/SrIT?'�' ! INrORMAT'I�CHANGES. 2. SUBMIT ON.Y ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the siic. \ lr\ 3 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. S. Use a hard point writing instrument, you aro making 3 copi,:s. Q G ( 9-Z 312 TOP OF FORM, "MARK ONLY ONE ITEM" f. to Mark an an (X) in the box next to the item that best describes the reason the fomr is being complctd L FACBITY/SITE DMRMA17ON& ADDRESS(MUST BE COMPLETED) i /�_� �O�,/ty L�� 1. Record name and address (physical location) of the underground tank(s). '3 0 '9 2- � NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACCIRPTABLE. Include nares((cross street and name of the operator. rrpp 2. Phone number must hatle an area code. If the night number is the same, write "SAME" in pi TLf yLTO`« 3. Check the appropriate bbbx for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, IeJll'r� I V f{�Il/QiYlt�• 4. Check the appropriate box for TYPE OF BUSINESS. ✓ 1 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the b II S 6. Indicate the NUMBER of TANKS at this SITE. �T IAlll� �0'CtY2- 7. Record the E.P.A. ID # or write "NONE" in the space provided. 1.^'.-.� H PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) CT//rt� b,/ ryt P,,e � 0'i'4.hti .'r�,,ttD hl AComplete all items in this section, unless all items are the same as SECTION 1; if the same, write --I T— this section. Be sure to check PROPERTY OWNERSHIP TYPE box. fka/AV":;> M. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) - - -- Complete all items in this section, unless all items are the same as SECTION 1: If the same, write "SAME AS SLIT." across this section. Be sure to check TANK OWNER4BP TYPE box. 'IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from 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 questions regarding the fee or exemptions, please call the BOE at 916-3239555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279.0001. V. PETROLEUM UST FINANCIAL RESPONSIBIIITY (MUST BE COMPLETED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. UM owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BELLING NOTIFICATIONS APPLICANT MUST SIGN AND DATE THE FORM AS INDICA7. INSTRLVT[ON FOR THE LOCA.AGENCIES Nounty and jurisdiction numbers aro predetermined and can be obtained by calling the State Board (916)739-2421. The faci number may be assigned by the local agency; however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. IT IS THE]RESPONSIBHITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THIS LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THIN "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O SWEEPS DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723