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INT,�MPLIJ(MONS K)R COMPIX-4 FORM 1tv
<br /> GENERAL INSTRUCEICYINS3,,
<br /> 1, One be all NUAl PURNIPC ('1111AING-FS jn", W,A(l I Jl'Y/SfFV
<br /> INFORMATION C,IANGVS
<br /> suilm.ri, ONLY ONE (1) FORM 'A' for a f`,acifivy`Sic, of ihl,� or
<br /> 3 '11is fc)rrli sbcmld bc, conirllelcd by either the PER�41'1APPOICANI'or ?hc s.00AL AGENCY U'Nl`tVRt;R011;'1,,t9
<br /> TANK INSPIXXOR,
<br /> 4, Plcavc ty f", or Pont d1carty nH r,cquested informalior"
<br /> t -c a hn�rd pcinl, wl-i6lig you 6'Y re making 3
<br /> ,3 s
<br /> 0P OF FORM- "MARK ONLY ONF' CIVNIx
<br /> Nlark an IX) to the box r,„xt to the itent that best describesOT, rcnson Ific js bcing Comp'lcilxL
<br /> li, mcu,nypsrn� n-4F,()RmA.-rroN & ADDRESS TtE COMPIT-11,13)
<br /> 1, Record na,rne Pod acrd cess (physical location) of the undergrolind lankf"s),
<br /> NOTF� Address MUST have, a valid physical location including city, suite. and -zip codc,
<br /> PCie 13OX NUMBEKS ARB NCI'Ji`ACC1qTAB11;-
<br /> Include nearest cross strcet and net" of the openator
<br /> 1 Phone nurnber must have an area code, If the tuomt la mlbcr is the same, wriic °AAMF` in proper localion,
<br /> 3. Check the appr-opriate box for TYPE OF BUSINE�SS OWNIRSHIP (ex. (.-ORK)RATION, INDIVIDUAL,
<br /> 4. Check the appropriate box for'°S OF BUSINE"SS,
<br /> S. IfFacility/Site is located within an Indian reservation or other' Indian trust lands, chuc� file box marked
<br /> & Indicate the NUMBER of TANKS at this srrr,.
<br /> 7. Record tire, F'�T,A11) # or write, "NONE" in the space. provided,
<br /> 11. Plpomwry OWNER INFORIMMION & ADDRE&S (MU51' BE COMPLE-11u))
<br /> Complete all items in this section, unless ail itents are the sarne as SF(TION 1: if' the -'arne, write 'SAME,AS SVIV
<br /> this section. Be sure to check TIROPEKI'Y OWN1,1ASHIP T'Yflfbox,
<br /> 111. TANK OWNER INFORMMION &ADDRRSS (MUSIAM COMPIX,1113)
<br /> Complete all hells in this section, unless all items are the salne, as FCFION 1; If the surveil write *SAME1 AS SITE acros,,,
<br /> this section. Be sure to checkTANK OWN UMSITHITYPE.' box.
<br /> TV. BOARD OF K)UMIZAITON US'I'MFORAGE Kill, AICCOUNI'NUMBER(MUsr BE compum.1,11))
<br /> 1."nt6r your Board of 1:.klualization (BOE') U91, Storage fee account number NA,,hich is required before your permit arij)fic�'Ilioll
<br /> can be processed. Registration with the BOTH will onsure that Arora will reccive a quarterly storluc Ice return ill rcilorlillc flue
<br /> %C06 (6 mills) per gallon fee due on the nurliber of allows pfaced in you USTII-. "she BOE will Code persons xa,nnpt from
<br /> paying the storage fee so returns will not be scat. If")a do not have all ico,,�ant number with the BOF or,if you hn%e any
<br /> questions regarding the fee or exemptions, please call tire 13013 at 910 323-95 5 nor write to the-1101", at the,followiw� addle�,,,:
<br /> Board of F'rjualization, Environmental Fee's Unit, P,O. Box 94287 , Sacrwj 100 1,
<br /> jcjj�rl, C;
<br /> V. P171'1tOLEUM USS FINANCIAL 11.ESPom'SH311'1ry (Mu"Tr B:F CoMP11,1-11,D)
<br /> Identify the method(s) used,by the owner and/or qperator in racefing, the Federal and State financial responsibility
<br /> requirements, USTs owned by any Federal or State agency,are exempt irc)m this requirement,
<br /> VL LEGAL Nf3`FJMCJVr10NANI3 13111ING ADDIUiSS
<br /> Check ONE BOX for the addres,; that will he used for BOTH 1JXlM,AND 1111 03 NOT1 "1(W11ONS.
<br /> APP11CAN71' MUSTSIGN AND DA71131TIE FORM AS INDI(W17111
<br /> m5muCHON FOR ITIE LO(AL AGENCIES
<br /> The county and jurisdiction numbers are predetermined arm can be obtained by calling the 'State Board (91,6)739-2421, The
<br /> Facility number may be assigned lw the local agency; however, lh=x, ntmabcr mil", be nunlerical arld Cannot Contain am,
<br /> alphabeticaL If the local agency prefers the State Board to assign Ole lacility na mnber. please leave it blank,
<br /> rr isum RusmNsimmy ozi-nitl FACUJIT TO VH Irk '111F
<br /> ACCURACY 01-1111iINFFORM MION, 'MIS APPIMMON CANN01' [if," PROCL,,"ED 111111E 130)E'A(,(X)UNf'
<br /> N€3 IE IS N(YI' F11114) IM '1111? LO(AL AGENCY IS RESPONSIBLE' FOR 3111l COMPLE11ON 011'111)3
<br /> *LOC ALAGUINCY USE ONLY' INFO RM)MON 1X)X AND FOR FORWAROINC3 ONE FORM "A" AND
<br /> ASSOCT ;MD FORM "iP(s)TO KMAX)WING ADDRE.13&
<br /> Int A'I'll OF CALIFORNIA,
<br /> C°tS 11EWNIER RESOURCTS MNWROL BOARD
<br /> C/o &W-TuLps.
<br /> DA717A PROMRSING CEMMM
<br /> P.O. 13O°C 527
<br /> POUMr, CA 90723
<br />
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