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GE : 1" 13("1 IC)N Sm
<br /> t; One FC WNI'A'shall be completed for allF, PERWAS,PE "I' HANGi?S or any FAC-lur /sirm
<br /> INIURMNIION CyEFAG13-S.
<br /> 2, '" 1. ONE(1)FX)RWA f€r a 1 acalctylSite,regardlessof the number of tanks located at the site:.
<br /> 3. This form should be complered by either the Pf.R1MrT' PPIJ1CANF or the .C) 1..,G17 C; .7NDE"1GROUND TANK
<br /> IN SP; "I"C)C.
<br /> Tease type or prion clearly allrequested information.
<br /> S. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP I'FOR ."MARK ONLY ONE I't'F:? "
<br /> 1. Mark an(X) in the box next to the item that best describes the reason the form is being completed,
<br /> . FCH T / ["IV,INN ) "I°ION&BSI DRfI ,as(M11 "IAF,CO Pix1IlVD)
<br /> 1. Record name and address;(physical location)of the underground tank(s).
<br /> NO E` .Address musr have a valid physical location including city,state,and zip code.
<br /> 1W.13C NUMBER bath$Nar Aawmntn
<br /> Include nearest cross street.and name of the operator,
<br /> '. Phone number moist have an area code, If the night number is the same,write",Sf1 v1I:3"in proper location,
<br /> 3. Check the appropriate box for'1"YPEi OF IIL?;sit FSS OWNI I21;1Fti' (ex. C::C:111I'C)TC.li'110N, ININVTi)(.AL,etc.)
<br /> 4, Check the appropriate box for TYPF OF BUSINESS.
<br /> S. If FacilityfSite.is located an land within an indian reservation or other indian trust lands,cheek the box smirked 'YES".
<br /> €i. Indicate the NUMBER of TANKS at this SITE1.
<br /> * Record the E.P. ,ID# or write'NONE" in the space provided.
<br /> tt. PROPERrY OWNER INFORMA110N&1ti7F)R (W'Sr BE C'0M1,1,F;`11,0)
<br /> T. Complete all items in this section,unless all items are the same as SECTION 1, if the same.write "S Ott? .S r."l?"across
<br /> this section. Be;wire to check PIE(7PE"RTY C)ta7N1 RSHIP'T°YP box,
<br /> III,TANK OWNPR INFORM/VIIONI?I)ldl-Sa S(h 11;x1'Bili f'CAmpunTiD)
<br /> 1, Complete all iteans in this section,unless all items are the same as SZ?.C'T`[ON 1; If the same,write*SAME AS ESrnI ,
<br /> across;this section. 13c sure to checkTANK C) Eit 1RSHIP°F"`iPH box.
<br /> IV BOARD Cif'HQUA11ZA'n0N usr Emil"C? GE MIE AEJB`["NUMBER(MU,51'ill?CO : 111-"3)
<br /> Fater your Board of f°:clualization (I3C)1:)USI'storage fee account number which is rectum°ed before your pe wit application can
<br /> be prmessed, Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the $0,(XY)
<br /> (G mills) per gallon feta:due on the number of galleons placed:in your t.S"7's. The 1101::`s will aide pers,ons exempt from paying;the
<br /> storage fee so returns will not be sent, If you do not have an account �number with the BOE.or if you have any quesoons
<br /> regarding the fee or exemptions,please call the BOE at 916-739-2,582 or write to the I3€aE at the following address:Board of
<br /> Equalization,Environmental Fees Unit,P.O. Wx 94287),Sacramento, CA 94279-0W1.
<br /> V. LIX3ALC)TIfgC'. '1IQ AND B1111W.1 At)Dilt03S
<br /> 1. Check ONE BOX for the address that will be used for Y111 LEGAL AND 3TI.I,TNG 0'I1F1 . `"EON&
<br /> APPLICANT MUSF SIGN AND DA`11i"1711 FORM AS I I , ITI).
<br /> IIS,WBIC.ICTIO POR T1ffI LOCAL AGEf, CIT?S"
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the;State Board (91€)739-2421.,fbe
<br /> facility numbest 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 /> TT lfs'I "TES RtspoNmany ciii rue 1,0C°. I. IAC ILTIT IT)VERIFY11IR
<br /> ACX , t' 017111H IWORMNITON. 'ITIS APPI.I AIION{ANN(Tr Bil Pltt a gip)n "fill?n E Acanwr
<br /> NUMBER I (yl` llsf. THE 1)C AL AGFNC Y IS R11SPONSIBIll FOR TI IR CJOMMIT110N OF11FII'LOCAL
<br /> AGENCY USE ONLY*INFORMATION ) I9 MR FORWARDING ONE FORM W AND ASS(W1XI11D FORM
<br /> W(s)TO'F'1 I3 lk}ILO I (3,21DDRE-S&
<br /> T IT CICS C` I1k)RNIA
<br /> A I A PROC14,SSING A_ I
<br /> P.O. )
<br /> PARAMOUNT, '
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