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INSTRUCTIONS FOR COMPLEUING DORM 'A" GENERAL INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERMPT.S, PERMIT C:IIANGES or any FACIIdTY/Si'l'l? INFORMATION CHANGES. 2. SUBMIT ONLY ONI? (1) FORM "A' for a Facility/Site, regardless of the number of tanks located at thc. site. 3. This form should be completed by either the PERMIT APPLICANT or the LOC'.AL,AGENCY UNDE R6ROUNU TANK INSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARK ONLY ONE ITEM" Mark an (X) in the box ncxr to the iteni that best describes the reason the form is being completed. L I+ACILTI9f%SPIE INFORMATION &ADDRESS(MUST BE COMPL i'T 31)) 1. Record name and add rew-(physical.location) of the underground tank(s). NOTE: Address MUST' have a valid physical location :ncluding city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACCEPTABLIL 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. CORPORA'T'ION, INI)IVII)UAT,. etc.) 4. Check the appropriate box for TYPE OF BUSINESS. . 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "1'Es". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. II) # or write "NONE" in the space provided. H. PROPERTY OWNER INFORMATION &ADDRESS (MUST BE COMPLLu"17D) Complete all items in this section, unless all items arc the same as SECTION 1; if the same, write "SAME;AS SrlV" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. '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 tillls"across this section. Be sure to check TANK OWNFWMI1P TYPE box. IV. BOARD OF EQUAIIM17ON UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPL.E'.IM) 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 BOF: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 916-323-9555 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 RESPONSIBILITY (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., VI 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 TME FORM AS INDICATED. INSTRUCTION FOR 111E 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 TIEE RESPONSIBILITY OF THE LOCAI,AGENCY THAT INSPECTS TILE FACILITY TO VERUiY TEIE ACCURACY OF THE INFORMATION. UHS APPLICATION CANNOT BE PROCESSED IF 11-JE BOE ACCOUNT' NUMBER IS NOT FILLED IN. TIIE LOCAL AGENCY IS RESPONSIBI:E?FOR THE COMPLETION OI,TETE *LOCM.AGENCY USE: ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS. STAI13 OF CALIFORNIA S17AIM WATER RESOURCES CONTROL BOARD C/O S:W-F-".& DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723