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GENERAL IMS,17RUCHONS:
<br /> I. One FORNI'A"shall be completed for all NEW PER M,PERMIFFC11ANGESor any MCPIlnY/srm
<br /> 2. simmu ONLY ONE(1)FORM 'A'for a.l^acuity°/Site,regardless of the number of tanks located at the site.
<br /> r-"'This fornn should be completed by either the PFIRMTTAPPmAw or the LOCAL AGENCY UNDIMMOUNDTANK
<br /> ilk. .
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3 copics, ,
<br /> TOP OFF[OR :"SARK ONLY ONE rMW
<br /> I, Mark an (X) in the box next to the item that best describes the reasonthe £omn isbeing co pt f6d. `
<br /> L I C11X1 /:s"I'I INI,-(XRMNITON&ADDWI.is, ' 'B t C;F9MPI,IrIiit3) °
<br /> 1 �orctsr a�ad and edd s(p(ty icaf; tion)of the underground tank.(,).
<br /> f3`ti" hddress MUSI have a valid physical location includincity,state,and zip code.
<br /> P.O.BOX NUMBER ARE'N(YFACCEFFABIM.
<br /> Include nearest cross street and name of the operaator.
<br /> r I'lsone n€mbar ust have an area scale. If the ,tight number is the same,write'SAME'in proper location.
<br /> 3. Check the approprituc bl;.11 for" YPE OF I:iUSIN ,SS OWNFRS IP(ex,CORPORATION, INDIVIDUAL,etc,)
<br /> , Check[be apprc)p:riate box for TYPT., OF BUSINIM,
<br /> S. If Facility/Site is located can land within an indiaan resets'ation or rather iridian trust lands,check the box_marked "YES".
<br /> 6, Indicate the `;[)MBER of`l=ANK,«i at this SITE
<br /> 7. Record the ETA, IT) # or write "NCy°tf3"in the space provided,
<br /> 11. PRIC]'Y OWNFR tFdFORM ITO ..DI) IM QWYMIE ETI7 ka 31, Y","
<br /> 1. ("ornplete all items ill this section, untess all items are the same as SECTION 1; if the same.write *SAMH AS SI'IT1"across
<br /> this section. Ike sure: to check PI2C3I"1"1MY OW:"Cl?RSfIIP°I'I'I'I;€`ox.'
<br /> II3.`I`AINK O.WhIER I" IORMNI°t("N& ,M-MRltSS( LPUI Bill CXYMPI a"ITID
<br /> 1. i S nplete all items in this'section,unless all stems are the sameas SEC-PION 1, If the,stune,write*SAME AS S171110
<br /> acro,this section, 11a sure to check TANK.OWNERSHIP' x'I'II ki� �.� � ( t
<br /> I I"ttlARD OF IIOUAIIMITON U I'M70R GE FEE CC:C UNI'NUMB R(must`BE
<br /> 0 t
<br /> t nter;,rour Board of Equalizalicm MOF,,') UISTstorage fee account number which is required beforeyour permit application can
<br /> istartiioaI s itPa ill e:nsuW that you will receive a quarterly storage fee return in r 4h t cA {k°a,
<br /> (r milts)per gallon fee due on the number of gallons placid in your i,S"l:s. The DCII:;will cede persons exempt from paying;the
<br /> s,t.orage fee so returns will not be sent. If you do not have an account number with the BOE or if you have any questions
<br /> regarding the fee or exemptions, please call the BOE at 916-739-1582 air wTite to the;DOE at the frallstwing address: Board of
<br /> Equalization,Environmental Fees Unit,P,O. Box 942179,Sacramento, CA 94279-0001,
<br /> V. T.,U sr'L fs(J"I717IC;r 11O AND IMI 3 ING I�I3I�RE-I-'a
<br /> 1. Check 0NI!'W)X for the address that will be:used for 13(:Y111 MIAL ANIS I3I .i C"r 1F1C JA'iN a �
<br /> APPIIC"1tN t(;N AND IWIM,IF1Il FORM AS I I I ° `ITM, °, w�,
<br /> �rp,y g g�ypx a'�D g g.y�.g^ �$ ,r g y..,�p�y g, .,. �
<br /> .ffi.d®�II�1.3"n�t.�t,md'q I�OWITI YeCF�.�a" LR�5.3Y.�.i CICS'...
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2421. The
<br /> facility number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the facility number,please leave it blank.
<br /> TIAS 17IFI ITIASI'f1N IBII.O'Y OFA' 11H WCAL AG C' '°ITIS"I INSTAIa.0 N`I`imx ly" . VI RI "ITIF
<br /> ;CURACY O 711 INFORMIVI10M T I IS APP[.ICA'nOPi (Yr BE PROC;IM10 IIt 17H3 130 113 ACCOUNr
<br /> NUMBER IS N(Yf F11,110 IN. '111E WCAL AGENCY IS iF?SPO S IiM IKA lTILI C OMP1 .11100 Olz"IIIE*110CAL
<br /> AGFNC'Y UM ONLY"INFORM)MON ON BO D IaC"itt FORWARDING ONE P()RM W .SCS . 'ITi FORM
<br /> "Ir(s)'I71 17II?ISI;.IOINfs I3I7U&s
<br /> C/o sm.11.1 ps.
<br /> P.O.BOX 527
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