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"FRUC.MONS FOR COMPLf;'"INCE FORM"A' ERAL INSITBU(7J1ONS; - 1. One FORM "A" shalt be completed for all NEW P171UWM, PERMrr C 1ANGES or any FACII.PI"Y/Sriv, INFORMNITON CHANGES. 2. SUBM17F ONLY ONE (3) K)R.M "A' for a Facility/Site, regardless of the number of hicks located 1st the �itc. 3., 'I`his form should be completed by either the PEi1tMIT APP11CAMF or the LOCAL AGENCY UNDIMGIZOUN1) ytSPF,CI"OR. 4. ' P ease type or print clearly all requested information. 5. Use a hard paint w'ritirlg instrument, you are making 3 copies. TOP OF FORAL "MARK ON'T.Y 11"M4 ;Mark an (X) in the box next to the item that best describes the reason the £oI•m is being completed. 1. FACRXI-YISTI`E3 INFO A11014 &.ADI)J1C.Tn.S (mum BE C:C 4miiu)) - 1. VRecord name and*address (physical location) of the underground tank(s). NO'I'E: Address %4USF have a valid physical location including city, state, and zip axle. P.O. 13OX NLTAMERS ARE NOrf AC:C.EF1:A131Ii Include nearest cross street and name of the operator. 2. Phone number must e anarea code. If the night numbir is the same, write SAM1" in proper locaiiort. 3. Check the appropriate x far`I"1,P OF BUSIN SS OWNERSHIP (ex. CORPO"11ON, INE)IVll:)UAf,, cic.) 4. Check the appropriate b x for nPE OF BUST: SS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YHS". 6. Indicate the NUMBER of TANKS at this SI'I'E:. 7. Record the RP.A. ID # or write "NONT-" in the space provided. 11. PROPERff OWNIM MAORMNLION &ikDDRILSS (MUST BE C'OMPIA--Cn?11) Complete all items in this section, unless all items are the sante as SE(nION 1, it h14 same, write 'S"F.AS SrIT;' across this section. Be sure to check PIkOPEWI'Y r3:"' M-1 'I YPE box. III. TANK OWNER INIFOIRMAITON & 't P 3RI r'S 1I1 C OMPLETFD) Complete all items in this section, unless all items are the same as SEC'T`ION 1; If the same, write ",SAME:AS Sup" acrs:>ss this section. Be sure to check 'F NK O" l`R-slTI" :€`yPF box. � IV. BOAR) OF EQUAT17WITON.U,51' F17W ACCOUNT NUM PR(MUEr BE C;OMPWITZ3) Enter your Board of Equalization i 13013) UST storage fee account number whA 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 USPS. 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 BOT, or if you have: ally 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, I=n-6ronmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PF-rROI.EUM UST RNANOAL RESPONSIBUX117Y (MUST BE COMPI,IJIT?D) 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 11?GAL NO"ITFICA1ION AND BRI ING ADDREM Cheek ONE 13OX for the address that will be used for BOnI LEGAL ANI) 1311.1 G N(XI F1C.A'n01 & ryPPLTC".A r MUST'SIGN AND D)VITi THE FORM AS INDICA1'FD. IN9I'RUC:11ON FOR"I711F,LOCAL AGENC I-13S The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The fao(li)r number may be assigned by the local agency however, this number trust be numerical and cannot contain any a' 1»tical. If the local agency prefers the State Board to assign the facility number, please leave it blank. 1'1'I S 171F, NS111311 1'Y OE T71E LOCAL ACYFNt Y 1' T IN SPX . N'I -EE?FACILTI'Y "I1) VERT 'ITtF ACCURACY OPnil" INFOR VIION. '11ES A€'PLICA`t'It`N NO'I'BE PROCF�iSFD Itr 111I1 BOL AC:C:OUN1' N iM TER IS NO(I`P'I111 1) IN. 'Ik1E`s WC AL At a� C,'Y IS RESPONSIBLE' F£)R'11 5 ("OMP3,13MONr OEC"11111 "LOCAL AGENCY USH ONLYI INFORMA11ON JA)K AND FOR 1X)RWARDING ONE FORM 'A'AND A.S.SOC T FORM 13"(s) '1`0 `1111 17011,0WING Al-W12E-S's, S'1'A11'OF CALIFCtagNiA Sr"A 1T= WA°I' R tt";rt t 1I£°1:RIi C ON'I°I OL BOARD C/ ,.°S DNIA PROC,I IN(J t;-1=.NJER P.O. BOX 527 PA MOUNT, CA 90723