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INSTRUC1710NS FOR COMPLEI NG FORM "A"
<br />GENFRAIL IN ONS-.,
<br />1. One 1,0 "A" shad be completed for all NEW PERMMS, PElzma CHANGEN or any FAC TI.ri y/sriv.
<br />04FORMA711ON CHANGES.
<br />2. r omy ONE (1)`17PRM "A" for a I ac'ility/Site, r(gardlcss of thenumberof tanks located at thc she,
<br />[ ;is form should be completed by either the PFI2Ii1iI" APIL C",rip ar the T,CiCAI. C�IiN( . UiV13I;I2Crl�illl l)
<br />'T'AN , INS'PE 100.
<br />4. Please type or print clearly all requested imormation.
<br />5. Use a hard point writing instrument, , ou aic peaking 3 copi. s.
<br />Ik
<br />TOP OF nt ~ "" " 12 CCIt `i�N $
<br />Mark an (3C) its the box next to the item that test describes the reass)n the form is being p9nipleted.
<br />I. FACH.I1Y/S '. BION & ADDRESS ( .13T BE COMM ffEEO)
<br />1. Record name and address (physical location) of the undergrount' tank(s).
<br />NCS. address MUST have a valid physical location including; city, state, and zip code. ,
<br />P 0. BOX NUMBERS ARE NOrCACCUPTABLE.
<br />Include nearest cross street and name of the operator,
<br />2. Phone number roust have an area code. If the night; number is the same, write "SAME" E" in proper location,
<br />3. , Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPOR)VI"I(:7N, INDIVIDUAL,, ctc.)
<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 '11.'S".
<br />6. " Indicate the NUMBER of TANKS at thisITE.
<br />7. Record the E.P.. IIS .dr, write. "NOin the space provided..
<br />IT., 'PROPERTY OWNER R07ORMAMON & ADDRESS (MUST BE CC?MPL r"I` ) ,
<br />Complete all items in this section, useless all items are the sante as SECTION 1; if the same, write "SAME !A,'S lSTI'I," across
<br />this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br />-TANK OWNER M40RMAMON & ADDRESS< L7Sr TTTT P s ) r ;
<br />Complete all items in this section, unless all items are, the same as SECTION 1; If the same, write "'. AS $rfli across
<br />this section. Be sure to check TANK OVINEIMUP TYPE box.
<br />TV. BOARD CTS EQUALIZAT11ON U GP, ITF- ACCOUNT Tt L3SI' BE f-T'C )
<br />Enter your Board of Equalization (BOE) USTstorage 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 storage fee return in reporting the
<br />$0.006 (6 mills) per gallon fee dire on the numberof gallons placed in your U s. Jbe BOE will code persons exempt froin
<br />paying the storage fee iso return$ wil4 not be sta If you do not have an account number witli the OV or`if, y()Ou' have aav
<br />questions regarding the fee or exemptions, please call the BOE at 916323-9555 or write to the BOE at .the following; addrens:
<br />Board of Equalization, Environmental Fees Unit, P.O:,Box,942879, Sacramento, CA 94279-0001,
<br />V. I'FrItC1I EEM, CJ NS ITa (MUST r C O RD)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. ' L7S'I's owned by any Federal or State agency are exempt from this requirement.
<br />VL LEGAL. NOTIFICATION °ION A 1 CI ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGALD B111ING N :1FI 'I°TONS.
<br />APPLICANT MUST SIGN AND DATE r FORM AS INDICATED.
<br />INSTRUCT[ON FOR THE LOCAL AGENOES
<br />The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (915)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 Board to assign the facility number, please leave it blank.
<br />IT IS THE RESPONSIBUXIT OF 111E, LOCAL AGENCY'ITIAT INSPECTS THE FACILnY To VERTFY`111E.
<br />ACCURACY OF THE INFORMATION. TMS APPLICATION CANNOT BE PIXY D ET AC T`
<br />NUMBERJS NOT FILLED IN. . L LIS, " ESP NR . COMPL , ON OF
<br />LO G IT non ,. r FOR FORWARDING, ® "V
<br />ASSOCIATFM FORM 'B'(s) TO TITIS FOLLOWING ADDRESS.
<br />STATE OF CALIFORNIA
<br />STATE WATER RESOURCES CONIROL BOARD
<br />/o
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA_90723
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