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<br /> Lt IONS FOR COMPI.TgIN0 FORM "A'
<br /> .. CSS LI. S rRU.. 0NS:
<br /> L One FORIN14""A" shall be completed for ail NEVPURmrrs,; I't imi,(11ANGES or any FACILITY/SITE''
<br /> f 3 F O TON C:l IANGTI—S.
<br /> i 2. SUB `ONLY ONE(1) F RM 'A' fora, Facility/kite, nguirdless of the number of t rnks locatedal tlrc siic.
<br /> 3. 17sis form should be completed by c€tier tine PEILIb1II'APHIG!r or the I ECAL AGFNCY CINIII€.1t6R01JNI.F
<br /> TANK INSPEI-L'CIIt
<br /> 4. Please, type or print clearly all rcclues,cu iwAormation.
<br /> ;< Use, a hard point writing instrumcnt„ (-ti an. making 3 cop.As.
<br /> ,rop OTT E R t "mARK oNLY"bNF? I t'tmo
<br /> Mark an (X) in the box next to the item ,.oaf ,st describes the reds,,n the form is bein eorapleted.
<br /> lecord name and address (physical 1<a
<br /> : Recordlaicr) of the undergs:aun" latsk(s).
<br /> N011.1. Address MUST have a valid ohvsical location rrtclu lines city, state, and zip code.
<br /> P.OBOX NUMBERS A.RE N,r ',ACC[WAB1JL
<br /> Include nearest cross street a,, nine of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same, write "SAXIE" in proper location.
<br /> 3, Check the appropriate box for TYPE OF BUSLNT-,',SS OWNERISIIIP (ex. CORPORATION, I:NINVIDUt L, etc,)
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian;trust land,, check the box marked "YFS".
<br /> '6: Indicate the NUMBER of'TANKS at this SITE.
<br /> 7. Record the E.P.A. ID # or°write"NONE" in the space prgwrided.
<br /> H. PROPERTY OWNER E -n0N &AI3DRLr,S`.S (MUST Iiia C O I.LgT-T3)
<br /> Complete all items in this section, unless all items are the sante as SFC"I'ION 1,,if;the sang, write. E AS SFITf" across
<br /> this section. Be sure to check PROPEI2'TY OWNERSHIP TYPE box.
<br /> M. TANK OWNER INII:ORIMATION &ADDRESS ( US'F BE CO PL 'ED) ;
<br /> Complete all items in this section, sinless all items are the same as SECTION 1; If the sante, write 'SAME AS Srlli°° across'
<br /> this section. Be sure to check TANK C) F.RB1nP tYPE box.
<br /> TV. BOARD CII EQU Z/01ON II T smoRAGR IST,ACCOU BER(MUST BF C O 11.7FED)
<br /> Enter your Board of Equalization (BOIL) 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 I;S`I's. The BOE will code persons exempt (ions
<br /> paying:the storage fee so.returns will not be sent. If you do not have an account munber frith the BOE or if you have a€sy'
<br /> questions regarding the fee or exemptions, please call the 130E at 916-323-9555 or write to the BOE at the following address:
<br /> Board:of Equalization, Environmental Fees Unit P.O. Box 942879, Sacramento. CA 94279-0001.
<br /> V. PL>I`ROL<EUM UST FINANCIAL -SPONSIBU (MUST BE f OMPLL .,IE)
<br /> Identify the method(s) used by the owner and/or operator in meeting the:Federal and State Financial responsibility
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> VI. LEGAL I*ICE1"ILWA'ION AND B111ING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEG)AL "3 BIHING W1114CATIONS.
<br /> APPLICAW MUST SIGN AND DATE THE FORM AS INDICATF13.
<br /> INSTRUCTION fk)R ITIE LOCAL ACIF.NCi{
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91.6)739-2421.. The
<br /> facility number may be assigned by the local agency; however, this number merit 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 /> fT IS'I`H! R .S N 11XJ'Y OF771E LOCAL AGENCY 7171A'T INS THE FA nY'Ito VERWY11
<br /> ACCURACY 011111E INFORMKITON. `ILII"ADPL ICA110N CANNOT BE PROCESSED IF7111.1 I?ACCOUNT'
<br /> NUMBER IS N(Yr FILLED IN. `[ilia' LOCAL AGENCY IS RESPONS113113 FOR 111E3 COMPI,EON OF 171 .
<br /> *LOCAL AGEN01 USE ONLY" INFORMN110N BOX AND,FOR FORWARDING, OW FCS "A"
<br /> ASSO "1 :I) ICOR "B"(s)TO 11IE FOU O ING . .DRF&Sm
<br /> SFA°IT,Clic CAIJFORNIA
<br /> STNI11lATE 'CIU -S CONTROL BOARD
<br /> c/o S 4
<br /> DNrA PROCESSING ITiR
<br /> P.O. BOA 527
<br /> PARAMOUNT, CA %723
<br />
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