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1NS1' IJC a'I0NJ a+r C C?MI'LLA INN FOVU41 "A'
<br /> 1. One FORIM "A" shall be compteted for all NEW PER 1S, PEI;n, C11ANCYRS or any FACILIry/snC,
<br /> INI?ORMJVIION CIIANGIS,
<br /> SUBMI`1"0N,1,Y ONE (1) ROOM "A" for s Facility/Sitea regardless of the number of tanks located at t t, iic.
<br /> I his forte - computed by either the P RNIFF APP11C,AN'T or the LOCAL AGENCY i1NI)I?IR112C7I:AD
<br /> 4. F°iti., r,t clearly all requested imbr€nation.
<br /> 5. USe a curd ptirft writing instrrumen€> you are making 3 copies.
<br /> TOP 017 FORM: 'MARK ONLY ON13 i'I'RM"
<br /> Mark an (X) in the box next: to the item that best describes the reason the form is being;completed. �
<br /> L Ia13.C1I I'I'Y/SV1 T,INIFORMN11ON &ADDRES', (MUST BE CCJIb P1,1t'IED)
<br /> 1. Record name and address (physical locatiois) of the underground tank(s).
<br /> NOTE: Address MUST have a valid Physical location including city, state, and zip. code.
<br /> P.0) BOX NUMBERS ARE NCIH'tACXMW ABU
<br /> Include nearest crass street and name of the operator.
<br /> 2. Phone number mast have an area codz. li tLe night number is the same, write "SAUCE" in proper location
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA11ON, I [MVIDUAL,
<br /> 4, Check the appropriate box for"I"YPE OF BUSINESS.
<br /> .5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES".
<br /> 6. Indicate the NUMBER of TANKS at this STI'E.
<br /> 7. Record the E.P.A. ID # or write 'NONE" in the space provided.
<br /> 11. €>Iz. 1-10-Y OWNER INFORMA-110N &ADDRESS SI'BE C OMPLI IT:T))
<br /> i crmplete all items in this section, unless all items are the same as SECTION 1; if the salve, write "SAME.AS-SJ'111° across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> III. TANK CT . E' 709MA110N c& AIII)ICI?S,S (MUST BE COMPLI . ? 3)
<br /> Complete all items in this section, unless all items are the sante as SECTION 3; If the same, write *,1. MI?AS ,rI1 across
<br /> this section. Be sure to check "TANK C)4iildFUM111 TYPE box.
<br /> IV. BOARD OF EQUALIZAITON USTSTORAGE t EE ACCOUNT NUMBER (MUST.BE 4P'C wl[.I.. m)
<br /> Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage: fee return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt: front
<br /> 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
<br /> questions regarding the fee or exemptions, please call the BOE at 91"6-323-9SSS or write to the BOE; at the following address:
<br /> Board of Equalization, Environmental FF° !-'aft, RO. Box 942579, Sacramento, CA 942794001.
<br /> V. PurlyOI.,E7UM UsT Fa[NANC]1AI,IZFS1'CI13;Cg il.t':. i`.1,WSE'BE COW1,171713,D)
<br /> Identify the method(s) used by the owner and/or operator in meeting the .Federal and State financial ;responsibility
<br /> requirements. US'Ts awned by any Federal or State agency are exempt from this requirement.
<br /> I. LEGAL NOrIMC KD tN 11'd'4711 B11L1Wi A DRE&S
<br /> Check ONE BOX for the address that will be used for BC3'TI-I lLI'K"L AND F3ILUNG NO'I1Ir1CA'11ONS.
<br /> AmICANr MUST SIGN AND BATF?THE FORM AS INDICA11M,
<br /> STRUCHON FOR'111E LOCAL AGEN iS �
<br /> "The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. `I°he
<br /> facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any
<br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> Tl"IS'11IF" Sl(N')NS1 BI ' ' OF" 1I3 LOCAL AGENCY`I IIAT INSPFX,`TS"W',FAC II 'ID VE? 1}Y'Till
<br /> ACCURACY OF]HE INFORMATION, TI FS AP kL>ICA'I ON CANNOT BE PROCESSED IF 114F WE ACC'OlJNF
<br /> NiTNIFB3'R t$4 Nk a l' IILLEII IN. 'I'EfF; LOCAL AGE:NC ' IS RESPONSIBLE FOR 11H' C'CTMT HT1 li=',1l OF`C°I l,"
<br /> s pf Ai Y`A;N ;g' USM O Y' 1NE()%NtXJJON FBOX 1) FOR IX)RWARDING CIN1:7FORM 'A"AND
<br /> IV
<br /> S.`O C;tA1 I ) J �' "B"(s)TO THE F01. WING ADDRESS.
<br /> SI"AT17 WKI Tf :ES CONTROL BOARD
<br /> C/o S .ILE.P.s, ,
<br /> A`IA PROCT-:SSING CENTER
<br /> PARAM06Nr, CA 90723
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