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1N5I.'RI.jC`11ONS I-OR COMPLF,11N<3 IX)RM, 'A'
<br /> 0-:
<br /> GV,NF,RAL INSI'RUCHONS,
<br /> 1, One FORM "` snail he completed for all Nl,,W PERMI'l'o, ITRMIT CHANGESf- FAVIIJIY/Sl H
<br /> IN1FORMN110N CTIANGFS.
<br /> ;LJBWFONLY ONE (1) FORM *A" fbr a Facilitv/sacj nardjess r t law, nuln'll-'I r,mi
<br /> 3. This form should be vc.)mpleted by either the H ,III' APPLICANI or flw LOCAl A(;I;N(Y LM)FWd,(W%j)
<br /> TANK INSIT"(71'OR.
<br /> 4, Plen,,� type or print clearly all requested information,
<br /> S. lyse a hard point writing instrument, you are making 3 copies,
<br /> 1101" OF FORMW 'MARK ONLY ONE 1`11.W
<br /> Mark an (X) in tL box next (0 the item*that bXt describes the
<br /> L FAC3111-f/SrIT INFDDRE&S
<br /> ORMA7110N & A (MUST' B13 coIT.I
<br /> mplED). IN
<br /> 1. Record name and address,(physical,loocation) of the underground tank(s),
<br /> NOTE. Address NA.tT htz,Wa valid.physical location Including cily, state. and .61) code,
<br /> 11.0. IXWNUMBFRS ARE N(Yr ACCIWA13111.
<br /> Include nearest cross street and name of' the operator,
<br /> 2. Phone number must have an area code. If the night number is the same. write "SekMf`" ill proper locillion,
<br /> 3. Check the appropriate box for'INPE 014' BUSINT',SS OWN't"1611111 (ex. CORPORA110N, INIAVIDU;,\L, etc,)
<br /> 4. Check the appropriate box for'nPE OF BUSINJ�'SS.
<br /> 5. If Facility/Site is located within in Indian reservation or other Indian trust lands. check the box marked Yl ',
<br /> 6. Indicate the NUMBER of TANKS at this Srll`s.
<br /> 7. Record the E_P.A. ID # or write "NONT3." in the space provided.
<br /> 11. PROPEWIT OW--c ill! (m1.Isrim,r6m1RIf-
<br /> nk
<br /> Complete all items in this sectik- -.s all items aru E*, same, Wnie 'FtAM11 ?%S
<br /> this section. Be sure to check I lit. ,,TY OWNERSHIP TYPE box.
<br /> 11L TANK 0"ER INFORMA7.nON &,AD1JR0SS (MUST' HE COMPIJ< 11:P)
<br /> X-'I( N-T� f`tia C same, rite ISAA!AS s,�
<br /> C ite all.item)i in As sectiotlArriless ail'iteniacct�\� Ihe sable as SH .,I mc�. W
<br /> 0ii�section. Be sure to check TANK 0VMHRS11UkTYPE box, l
<br /> IV, BOARD OF WUAIIZJV.IION 1JSI'9J'0RAG1I 141-iF.AC(.,;OUN`I' NUMtER (R 0§I"
<br /> Lilte I r yqur Board ol'Equ41tlizAi' AiNdl is,',rcq�uirspekin z
<br /> oil (13011) usr storage fee account nurather
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly sh.)raoc fee I`Cttffi�
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in yowr USJ's. The will code per
<br /> paying the storage fee so returns %011 not be sent,, If You do not have in account llUn1hCr With, the 1301" zc,I V
<br /> questions regarding the foe or exemptions,please?call the BOE at W-32,3-95.55 or w6te to the 601' at the, ,,wing akldrcs,,,:
<br /> Board of I ualizatioa, Environmental Fees Unit, P.OBox 94212779, CA 94279-000L
<br /> V. PE-IROI.14.UM. UST' FINANCIAL RuspoNsmun-Y (m05.r Bu co141p1.t.,11a))
<br /> Identify the meth6d(s)'uscd tire-6wner and/or-operator in inceting the Fcd�ral and StRe f1blandil rc',,,ponsibilny
<br /> requirements. oWjlet! any Inderal or State agency are exempt from this requirement.
<br /> VL HiGAL NGIMI(WHON AND IN]LLNG ADDRESS
<br /> Check ONIE BOX for the address that will be used for 130111 IJIGAL AND BILIING 1NO'111`11CA11ON'S
<br /> APPLICAN'r MUST'SIGN AND DXIL�'17111137 FORM AS INDICNITID,
<br /> TW1'.RUCJ1ON FOR11111 LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91.6)739-242L '['he
<br /> facility, number may be assigned by the local agency: however, this number inust be numerical and cannot contain any
<br /> alpha6clica", If the local agency prefer,,; the State Board to assign the facility number, please leave it blank.
<br /> IT 1S 7111 RUSPONS1131111T OF 111171 LOCAL A6124,7Y THAr INSPIX717S111B FACILITY TO N 'a gat;
<br /> ACCURACT OF 1111s INFORMNITON. 'IITIS AI` T,i(wriON CANN(Y1' 13E PROCE;SSI'D 1171111i W'7( A,'= OI.JNI'
<br /> X
<br /> NUMBER IS Wff I'LLED IN. 7111' LL WAAGENCY IS RESPONSI[BLE IX)R C'111F )MI1111,110", fli, a011i
<br /> "LOCAL AGENCY USE ONLY" IN1FORMA11ON JXYX AND FOR FORWARDING ONE FORM 'A; AN l)
<br /> A.`"0A'110 FORM "iY(s,) TO '11113 FOLLOWING ADDRE-SS.
<br /> S1WIT' OF CALIFORNIA
<br /> 40WIT'
<br /> WA'ITR RI,_S0U1tCF_S CONNFROL IX)ARD
<br /> C/O im_Enm�,L
<br /> DNIA PROCM&SING CErqI'FR
<br /> P.O. BOX 527
<br /> PARAMOUNF, CA 90n3
<br />
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