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0,k,,WA 40
<br /> 4 vm
<br /> TNS`1RU `11ONSFOR COMPLI117ING F()RM 'A'
<br /> (3ENER/U, lN`SRUC`D0NS-
<br /> 1 - 'R 'S or any FACILFIN/Si'll
<br /> f°ne FORM "A' shall be complelcd for all NEW PIN MON, PERM
<br /> INFORMiVOON 01ANGE&
<br /> 2, S1,1111WHONLY ONE (1) FORM 'A' for a Facifity/She, regardless of alae In lroc of nulks, tocare d ;,i: th",
<br /> fb,m !.,hould be comple't'-d' by either the lTIZMlTAPPI1CANtor flhv, )CAL AGENCY UNDI 1'(;J,(WND
<br /> TK f
<br /> T!%N NSPHC`1Y)R,
<br /> f1vasc
<br /> pc or pnnt cicarly all requested infra nnation.
<br /> 5, 1-:S" '-I r,"a-rx'j Pairst ,,vHdng insamerrt, you are niaking 3 copies.
<br /> TOP OV' PP'1')RM.-, 'PNIARK ONL's' ONE 91TAP
<br /> Mark an (X) in The box nom to the item that best describes the reason the form is being completed.
<br /> I. izmdurypsm.�INFORMNTION A ADDRE-s-S (MUSt' BE COMP113TH70)
<br /> I, Record nate and address (physical location) of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code,
<br /> O. BOX NUM-13U."WS ARJI NOT AM-MA1,311L
<br /> Include nearest cross street and name of the operator.
<br /> 1 Phone number raust have an area code, If the night number is the sanice w-rite "'.13"WE'" in Proper locahon,
<br /> 1 Check the appropriate box forTYPEL 01' BUSINE'SS OWNERSHIP (ex, COR1'OR/0-ION, INIAVIDUAL, etc.)
<br /> 4, Check the appropriate box for 'Fl(PE OF BUSINESS,
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust-lands, check the box marked YFS".
<br /> 6, Indicate the NUMBER of TANKS at this SITE,
<br /> 1, " in the space provided,
<br /> I Record the ETA, ID # or write `NO.'o.F
<br /> 11, P110I11dZ-f5? OWNER MtORMNn0?sF&ADDR03's (musr BE comptimm)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAMF AS S1IT7
<br /> this section, Be sure to check PROPEWFY OWNERSHIP I-ITE box.
<br /> 111. TANK OWNER INFORMA110N &ADDRE&S (MLJ,",'-FBU CoMPLM-10)
<br /> Coniplete all items in th;& section, unless all items are the same as SE `FION 1; If the same, wrile 'SAME AS STIT,7 ftcl,OSS
<br /> this section. Be sure to check TANK OWNERSHIP TYPE box,
<br /> IV. BOARD OF FOUAT17MION U,O'S'FORAGE FEE ACCOUNr NUMBER(MU,(;r BE COMPTHIVD)
<br /> Enter your Board of Equalization (1100) US-r 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 ihe
<br /> 50,006 (6 mills) per gallon fee due on the number of gallons placed in your US1-s. The ROE will code persons exempt from
<br /> paying the storage fee so returns will not be sent, If you do not have an account number with the BOF' or if you have, any
<br /> questiote; regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the folli�)vin- address:
<br /> Board of Equalization, Envircatmemal I"ces Unit, P,O, Box 942879, Sacramento, CA 94279-0001.
<br /> V. PETTROLELIM LT IMNANCLAT,RE.SPONSIBU.,rry (mLd;T BE COMPI
<br /> Idem,ify the method(s) twed by the owner ind/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any l"ederal or State agency are exempt front this requirement.
<br /> V1. IJHGAL WYOFICAIIONAND B111ING ADDRESS
<br /> Check Cy "I2BOX fir)r the address that will be used for BOTH HilGAL AND 131 C1 N01119(WOONS.
<br /> AFrucAmr SMUST SIGN AND DAI 'ITIE FORP-d jNS M, )MWJT1D,
<br /> INS'ERUC]ION' FOR111E LOCAL AGENClES
<br /> Thc cou,
<br /> J my and just sdiction numbers, are predeternrined and can be, obtained by calling the State Board (916)739-2421, The
<br /> ,ucflitv, number may he avigred 1-my the local agency; however, this number must be numerical and cannot contain ariv
<br /> af-phabefical. Mthe local agency prefers the State Board to assign the facility munber, please leave it blank.
<br /> IT To ITIF RESPONSIBILTIN OF 11114 LOC-M-AG]SN(,Y THKF INSPEC'S,'111E FACIUTY TO VEWIFY'11W
<br /> ACC'URACY OF THE INFORNINFION, 'ORS APHICs TION CANNOT DF PROCESSED 117 ITTE 13O1A—A(X-'OIJN71'
<br /> NUNIT171,"R IS NCL]' FILLED IN, TY III LOC 1< AG1WCY IS RRSPONSTBII.�,' FO.R 11113 COMPW 1710N OF'1111;
<br /> 'LO(AL AGENCY USE' ONLY' INFORMAK17][ON'BOX AND FOR FORWARDING ONE FORM 'A' AND
<br /> ,AyN0C13/Vf1ED FORM lli'(s)TC) 11,011,11YWIN(1 ADDRESS-
<br /> S71WIT'
<br /> OF CALIFORNIA
<br /> ''3 NI` RESOURCEN CON17ROT,BOARD
<br /> DKIA, PROCU-SISING C W11,11
<br /> P,O, PDX 527
<br /> PARAMOUNF, CA 90723
<br />
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