|
e"',:,'2 ` ., $ �;,�i.'sk°t,, '``,`�:`'" z
<br /> C ENr, I..TIAs TW C:rK)NS:
<br /> l wltt } li bcompleted for all NEWPERMITS, PERMFI' `ff SSI GEN or any FAC71TI'°n//FIV
<br /> \1110N C1
<br /> S (3zMfr ON ONF 1)' *O W fur 7 scifity/Sate, regardless of the number r of tanks loc i ed at t(1
<br /> d ho completed by either the 111"R Iri APPIK°.A 'or the L CAL,AGI., CN LzN`Ia1iItGROILI' D
<br /> 4, Please type or print -learly all reclrrested information.
<br /> 5. Lasa: a harm point.writing; instrunrent, ]oa.y are itrakim, 3 copies:
<br /> TO Ir I II£ : WARK,OXLY,OOP ;i' ,,
<br /> an (X) in the box next to the item that best describes the.reason the f(,aVm`is lacing completed,
<br /> L TSA SII fry/SrIT!, INFO -110 DIIIMS( IUSM BE OMPLINE
<br /> ,
<br /> L Record name and address (physical lo(lation) of the; underground tank(s).
<br /> NOTE: Address MUSThave a valid physical location including city, state, and rip toile.
<br /> PO. BOX NUMBERS ARE N(A'ACC12TABUL
<br /> Include nearest cross street and name of the: operator,
<br /> 2. 'Phone. number must have,an area code. It the night number is the same, write "SAME" in proper location,
<br /> 3. Check the appropriate box for nPE OF BUSINESS OWNERSHIP (ex.'C'Oi2PC9CtA't1O , INIXVID AL, 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 lands, check the box marked "YE's",
<br /> 6. Indicate the NUMHEI2..o€TANKS at this`SITE
<br /> Record the E.PA.-ID .orf write ,,NONE. "in the space provided.
<br /> it. PAomary,owmp,wFoRMATiOld . ° ( . SrTSE. iaa )
<br /> Complete all items in this section, unless; all items are the same as SI,CwnON 1: if the same, write *SAME AS sri°tt:, across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> J[L,,,TANK 0,WNIVR IN A I„R1,i (MUS`F1P_ C) PI Vb)
<br /> Complete all items in this section, unless all items are the same as SECTION i; If the same, write 'SAME AS sn'E, across
<br /> this`sectiom Be sure to sheck TANK OWNERSHIP TYPE box.
<br /> ]V� "BOAlUi OF E0TjAUZAT1QNqW SIORAGE FEL ACCOU EIS US"T"BE I,Tsm -al)
<br /> Enter your Board of FAvalization (110E) UK' 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 stor�age`fee return hi reporting the
<br /> $0.006 (6-mills) per gallon ee'tlue on the number of gallons placed in your US`C`s. The BOE will code persons exempt frons .
<br /> pay°ingA6"stcsrage fe .so ribrns will not be"rs6m. T yow do not have an accotint number with the BOE or if`you have any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address:
<br /> Board of Equalization, Environmental Fees Unit, P,O. £lax 942879, Sacramento, CA 94279-4001.
<br /> E'FRO111111UM USTT . - ESPONSIBILn (MUSr BB CES' LUMD)
<br /> Idcnnft; the method(s) used by the owner and/or operator in tweeting the Federal and State financial responsibility
<br /> requirements. t191's owned by any Federal or State agency are exempt from this reguirement.
<br /> VIe LEGAL ht011FIC,ATIO AND D111ING,ADDRESS
<br /> Check ONE BOX for the address that will be used for tiE)TH LFGAI.AND IkIJING N071114CKPIONS.
<br /> PIKAIxI°I'MUSI`SIGN AND )AIL?"1"RL 17ORM AS MI(W111D.
<br /> 1NS`1'RUCM0N FOR THE LOCAL AGENCHIS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Hoard (91.6)739.2.121: 'rhe
<br /> facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any
<br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> IT IS 1HE a 1"Y.OF'11H! LOCAL AGENCY "111A'T"I SPECIS 111,IQAC[Ln`I'TO VFAWY°1111
<br /> ACCURACY Y OF 171E I FO ITON. °IVIS APPLIC;/la" ION CANNOT BE PRO `FM IFF,DOE ACCOUNF
<br /> NUMBEROLO ';T> IS 14 -nON BOX AND POWFORWARDIM RM 'A'AND
<br /> 0T FILLED IN.
<br /> C `°.s11J E LOCAL ACII« _,1 R , l ,.fit) PL C3N 01 r
<br /> MA
<br /> ASSOCIATED I TC 'B'(s)TO IIIE FOLLOWING ALIT,RJ S� e
<br /> SI7A1 ; 017 CA11FORNIA
<br /> S I Al i A FEF RESOURCE-S WNWR )T.BOARD
<br /> C/o .I T$P.x
<br /> PO. BOX 527 g^%,g
<br /> TSA 'MOM , CA 90723
<br />
|