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71
<br /> IMFFRUCHONS FOR(_'ON1PIJTPI&RM W
<br /> G0NI!RA,,'-1 '11'T;I RUMIONS:
<br /> 1, One FORM "A"shall be completed for all NIM PFR I'S,PERWYCHANGOS or any FAC11MY/Sri33
<br /> INFORmNnON CITAN60S.
<br /> 1 sunmrr ONLY ONI,'(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the sits'.
<br /> 3. This form should be completed by either the PERMfl'APP11CAMF or the L0CALA(W'.NCY UNI)=e'RGROLTNII' TANK
<br /> INSPIK'FOR.
<br /> _4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF FORM:*MARK ONLY ONII IrII7.M*
<br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FAcilury/sirm, INFORMA-11ON&ADDR1z_Ss(musr BE a)Mpunn))
<br /> L Record name and address(physical location)of the underground tank(s).
<br /> NOTE Address MUST have a valid physical location including city,state,and zip code.
<br /> P.O.BOX NUMBER ARP NOT AmmiymBuL
<br /> Include nearest cross street and narne of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAMF'' in proper k;nton.
<br /> 3. Check the appropriate box for TYPI'l OF BUSINESS OWNERSHIP (ex, COR11012ATION, INlW,,'lDLJAL,etc,)
<br /> 4. Check the appropriate box forTYPE OF BUSINI-,SS.
<br /> 5. If Facility/Site is located on land within an indian resenration or other indian trust lands, check the t�ox marked "Y S".
<br /> 6. Indicate the NUMBER of TANKS at this SITE
<br /> 7. Record the E.P.A. 11) # or write'NONE" in the space provided.
<br /> IT. PROPERTY OWNER INFORMAIION&ADDRI_,Ss(MUSE'BE COMPHMT))
<br /> 1, Complete all items in this section, unies.,all items are the same as SFX_TION 1: if the same, write 'SAMF AS SITT.*across
<br /> this section. Be sure to check PIWPFIR'n OWNF.RSHIPTYPEbox.
<br /> III,TANK OWNEIR INFO RMN)ION r&ADRI 31;S(MUS-1-Ill`"_)MPI,FrF1))
<br /> L 0)mplete all items in thi,,section, unless all items are the swne as `sic ry)N 1; If the same,write *SAME AS ME'
<br /> across this section. Be sure to checkTANK OWNERS11111"ITPH sox,
<br /> IV I-X)ARM OF FUALMMION US11','UORAGE Fl l3 ACCOUNI-NUMBER(MIJ,1;FBf1 COMI-1111a))
<br /> Fmtcr your Board of Equalization (BOI-I'l) USIrStOrMF fee account number which is required before your permit application can
<br /> be pi.wessed. Registration with the BOE will ensure that you will receive a quarterly stowage fee return inreportifty the`PMW
<br /> (6 mills)per gallon fee due on the number of gallons placed in your USTs. The BOE vxill code persons exempt from paying the
<br /> storage fee so returns will not be sent. If you do not have an account numlcr with the BOL.*or if you have any questions
<br /> regarding the fee or exemptions,please call the BOF at 916'139-2582 or Write to the B0117 at the following address: Board of
<br /> F,qualizati 'Frvironmental Fees Unit,P.O. Box 942879,Sacramento, CA 94279-00(01.
<br /> V, LIX.iAL ) :' _',1'0,`4 A = 31LIJNG ADDR3_53i
<br /> 1. Check ONJ' W)X for the address that will be used for BkM1 Irl'XiAl,AND 1311.11NO N(YM4CA`l`IONS.
<br /> APPLICAMr MU1517SIGN AND JJJVM'I1M FORM AS INDICAIM.
<br /> IN517RUMON FOR'flfli IMAL AGINCM-S
<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 agenev; 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 /> Rl[;f' a,tro1NP0NSIBIIr1"Y OF*1111i IA')CALGFNC
<br /> AY'J1IA`I`1NSPFCfN'111E FACIIXIT TO WRIPY111M.
<br /> THIS r�1'"LIC�"ION CANNM'1111 PROCfLWi`0 IF111EMEACCOUNT
<br /> T!M 1,0CAL A(;! NCY IS R0SPONSIBIE MR 111C,COMP11MON OF'111E*LOCAL
<br /> U�,4',OINTY' 7PA?0RMA'110,N IK),v,AN ) 1`0,2,VORWARD',ING ONI!MRM*A*AND ASSOCIA7MI)FORM
<br /> 1131ts) l7W,FOLI oINING AIMIWI_'"
<br /> 4]'A II;;OF CALIFORNIA
<br /> S'I'ATI', WYVITR HF,X)IJRCMI,:"OMYROL BOARD
<br /> DATA ?ROM�S�TN(. (I"VIIIN
<br /> P.O.BOX 527
<br /> PARAMOIJNI�CA 9VM
<br />
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