|
INSMUM6NS' VOR, ir-�OMP'ixnNCY FORM "A!
<br />GINFRAL
<br />'ha, 6e completedfor all NEW p I"1 , Fi?Rmn, CHAhGEN or any IsAC'IL.rIy/sf11;
<br />.sem_ tF��ErS,
<br />2. SUDIviff lhii sari (1) for as Facility/She rgardtess of the number of hanks located =at
<br />sa•' In be completed by either the I'3=ItMrr Ak'PLIC`,AKI'-or the 'IS)C,AT, AWINC Y C:NI)'E;ItCtROI-IND
<br />t TANK fNS'FF,Cr0
<br />4. Please type or print clearly all requested information.
<br />5.ase a hard point writing instrument, you are making:3 copies.
<br />TOP OF
<br />, .;< an (X) in the box next to the items that -best describes the reason the form is l�eirtg`cgaarplctccl,
<br />L FA(s1U 17/Sr .: , 11th ADD + . " ( 51" BE t;C)t I'I:,E; ITT) ,
<br />1, Record name and address (physical'lti tion) of the underground tank(s).
<br />NOTE": Address MUST have a validphysical location including city, State, and rip code.
<br />P.O. BOX NUMBERSARE (Yr ACCFYTABU1
<br />Includes nearest cross street and name of the operator.
<br />2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location,
<br />3. Check the appropriate box for TYPE OF BUSINI OWNERSHIP (ex. C'C512PORA"I"ION, INDIVIDUAL, etc.)
<br />4. Check the:; appropriate box for TYPE OF BUSINESS..
<br />5. If Facility/Site is located within an Indian reservation or other Iridian, trust lands, check the box marked' ' f1 S'.
<br />'--6._ .Indicate, the 2diJi4lBEII of-.,rAN'KS at -this SIFE.
<br />7. Record the EXA-.11 cxr' witt, "im NIF" in the: s ace presvidcdS'
<br />Complete all items in this section, unless all items are the same as SEC"I:It: N 1; if the same, write 'SAME AS SI T.' across
<br />this section, Be sure to check PROPEROWNS ZSHIP `F`YPE boss,
<br />4".-JANK OWE A.. N, 4,<ADII, K ( Sr-COMPl..MUD)
<br />Complete all items in, this section, unless all items are the sante as SECTION 1: if the same, write "SAINT? s srl`ir" acr�ose '
<br />this section. Be sure to check TANK OWNERSHIP TYPE box.
<br />11)(> DOAJD_C3 _ EQUAPM1, t1.ST SJR GB, IME, ACK'COU E3 (musr Byi comp 110)
<br />Enter your .Board of Equalization (DO) LIST storage fee account number which is required before _yearn pernik application
<br />can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting tlw
<br />00,6- (Cr mills) per kallpti fee due on the number of galleins placed in your US`T`s. the, BOE will code .persons seem pt €ream
<br />I pay°in ;thc"strkr "e'fe "sts.
<br />re ` n 'll nob be," att� �If ycrXe` do not have tan account number�vwith ihe'I3C9F; or if you have'any
<br />questions regarding the fee or exernptions, please call the BOB at 9I6-323-9555 or write to the BOE at the following addtcss:
<br />Board of Equalization, Environmental Fees Unit, P.O, ilox 942579, Sacramento, CA 94219-0001,.:
<br />. VeC,FROLHUM U .. .. 11$1., (MUST t°C7 =,)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements, LSTs owned by any Federal or State agency are exempt from this requirement.
<br />TCF, LEGAL idtT nF1 ' ON B111ING ADDRESS
<br />Check ONE BOX for the address that wilt be used for 3OnI LWAL AND B111ING N(Y.11FICA11ONS.
<br />APPLIC W MUST SIGN AND DA.. '1"HE FX)RM AS 1 I).
<br />The county and', jurisdiction numbers are predetermined and can be obtained by calling the State hoard (91.11)739-2421:. The
<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 hoard to assign the facility number, please; leave it blank.
<br />rr 1S `111E 1 OF M I I' LOCAL AGENCY II IAT INSP '111E FACj1JTY TO VFMFYI EIE
<br />ACCURACY OF °L ICI is S A.PPLICrK1101 i BE ARCA SEAT), IIr WE BOE AC; 1°
<br />NUMBER IS NOT, FII}b ill IN. 111E TDCAL AGW4CY IS I-SPON 1,E FOR111E COMPIJq1ON OF 111E
<br />"T ro E, -AGENCY USE ONLY" INPORMKIION BOX AND FOR'176RWARDING ONE FORM "A" AND
<br />,
<br />ASSC 1 ]PO W(s) T '111B 1� I1 , ' I A 12F ';
<br />STATE CTT C;A11FO A
<br />S�rATFWAIER RESOURCES COKIROL BOARD
<br />6AtA h MS I CI VIER
<br />P.O. BOX 527
<br />
|