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INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: 1, One FORM "A" shall be completed for all NEW PERMITS, PERMIT CIIANGFS or any FACBd1Y/Sriv !NFORMATION CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the soc. "1'1ds fors+ 0, old be completed by either the PERMIT APPLICANT or the LOCAL AGFNCY UNDERGROUND 'TANK INSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OP,Fd M- "MARX ONLY ONE ITEM" Mark an (X) in the box next to the item that best describes the reason the fops is being completed., , L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code., P.O. BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator., 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, elc.) 4. Check the appropriate box for TYPE OF BUSINESS. S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indicate the NUMBER of TANKS at this SITE 7. Record the E.P.A. ID P or write "NONE" in the space prdvided. - -, H PROPERTY OWNER DWORMAMON&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 SRT!" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. UL TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION,l; If the same, write "SAME AS SITE" across. this section. Be sure to check TANK OWNERSHIP TPE Ybox. - TV. 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 UM. 'The DOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account nomnber with lt)e DOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the DOE, at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879;Sacramento, CA.94279+0001: .V.. ,PETROLEUM UST PINANCG!.I"RFSRONSIBH.117Y..(MUST BE COMPLETED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs 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 BILLING NOTIFICATIONS APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facility 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 RESPONSBUX17Y OF.TILE LOCAL AGENCY THAT INSPECTS THE FACBdIY TO VEM]PY'IIIE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL.AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "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 &wm"--. DATA PROCESSING CENTER - - - - P.O. BOX 527 PARAMOUNT, CA 1%M