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IN917RUC711ONS FOR COMPLETING 1k)RM 'A" GEM'RAL INSTRUCT]IONS: 1, One FORM "A" shatl he, complcied for all NEV Pl."RMITS, PlAmn, 0lANGE-S ,-- anFACHSI'V/SITF, INFORMATION CITANGIN. 2. SUBM.171'ONLY ONE (1) FORM W for a Facility/Siie, regardless of the number of lanks localol at 01,; i!c. 3, 'this form should be completed by either the PF'RMfl' APPLICANI'or i lic LOCAL AGENCY UNDI !\l TANK IN,,ii"T'(J'OR. Please tylx; ,'V print clearly all requested information. ') 5. Use a hard point writing i�tlstrunient, you are making 3 copies. TOP OF I1OR'A- "MARK ONLY ONI-i 1`111"M" Mark aN (,X) i'il the box next to�tiie immlhai-besi describes the reason the Torm'il I,eing coml.Actezl. I. mcnrrypsnT. RQAORMA:IION &ADDROSS (MUSE BF COMPLE-110) 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 NUMDEJUS ARE W.I'ACC17FABI.H. Include nearest cross street and name of the operator. Ik,) 2. Phone number must have an area code. If the night number is the same. write "SAME"' in proper location. 1 Check the appropriate box for TYPE OF BUSINESS OWNERSIJIJy(ex, CORP0RA,nc)Nr. INDIVIDUAL, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 'V, 5. 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 # or write "NONE" in the space provided. 11. PROPERTY OWNER INFOR.MNJION &ADDRESS (MUST BE COMPTH170)) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write. -SAME AS srjv" across this section. Ile sure to check PROPERTY OWNERSHIP TYPE box. ILL. TANK OWNER IMIORM/01ON & ADDRESS (MUST BE COMPL13n-ED) Complete all items in this section wiles an itAs are the same as SECT16N1: If the same. write *SAWE AS SITE aerciss k this section. Be sure to check '13L OWNERSITIPTYPE box. IV. BOARD 017 EOUAIXZATION Lisr SI!ORAGV IT.E ACCOUNT NUMBER (MUST BE COMPI.tfna)) 'Enter your Board Of Equalization iNE) U51,stor,41, 'fee account number which is required before your*prillit applIcalion can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee rett �1 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 fi-oill paying the storage fee so retur s will not be sent. If you do not have an account number with the BOF' or if you have any questions regarding the fee or exernhtions, please call the BOE at 9116-323-9555 or write to the BOE at-the'.1,61lowillo address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. C r.IT.D V. PETROLEUMS-['ROLEUM UFINANCIAL R -OMPI- I3SPONSIB1Ln Y (MUST BE identify lhd method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility. requirements. USTs owned by any f'ederal or State agency are exempt from this requirement. VI. LEGAL NOT[FIC/VI'ION AND BUJING ADDRESS Check ONE BOX for the address that will be used for BOTII LEGAL AND BILLING NOTIFICATIONS. APPIACAMr MUSI'SIGN AND DA'113 T11F FORM AS INDICWI'FD. INSTRUC11ON FYOR 11111 LOCAL,A(JENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91.6)719-2421. 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'111E RESPONSIMIXI-Y OF WE LOCAL AGErQCIV -,tT'C`IS THE FACILrIY TO VERIFY 11W ACCURACY OF TI IF INFORMA7110N, '11115 APPI.JCA V RE PROCESSED IF TILE BOE ACCOUNT NUMBER IS NOT' HPI,' 11) IN. 'I HE LOCAL AGINCY IS tel FOR`17IE COMPL1.4.37ON OF 1.1111 "JZ113ING ONE FORM W AND "LOCAL AGENCY US],'. ONLY" INFORMA11ON 13OX AND ' ASSOCIATED FORM W(s) -1-0 FOIJAW]ING ADDRES's. SPATE?TATE? OF CALIFORNIA ITIWIE WAIV'R RESOURCT-S COMIRol. 19)ARD C 0 &W-F-E�P-Vx PROCESSING CENIER P.10.1 BOX 527 PARAMOUNT, CA 90723