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INSI"Rucm..)NS FOR (.,,o.rll ix,."ITNG FORM A"
<br /> 1, One I'`C)RM "A" shalt be completed for all .NEW PERMTI'S, PERMI'r CIIANGEN or any FACILYIN/SI'11:
<br /> ]Nfk)RMKIION CHANG&S.
<br /> 2. SUBMrr ONLY ONE (1) FORM "A° for a Facility/Site, re-gardless of the number of tanks located at the site.
<br /> 3. This form should he completed by either the PERMIT API'I,.IC°AN'T or the LOCAL AGE NCY UNDI:RGROU D
<br /> TANK INSPE?C'TOR.
<br /> pe *sr print clearly all requested information.
<br /> t_15 a Bard point writing instrument, you are making 3 copies.
<br /> I ;� „: :.Ia ONLY ONE 'ITEM”- —
<br /> Mlark an (X) in the box next to the item that.best dpscribes the reason the form is being completed.
<br /> I. UAC.11X1"Y1S1'I'E IaNFORMA-110N &ADDRW� (MUST' BE C:OMPJ.1411sD)
<br /> 1. Record name and address (physical location) of the underground tank(s).
<br /> NOTES: Address MUST have a valid physical location including city, state, and rip code.
<br /> P.O. 13OX NUMBERS ARE NCYr ACCLWABI.I?.
<br /> Include nearest cross street ar,l name of the operator.
<br /> 2. Phone slumber 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 014' BUSINESS OWNERSHIP (ex. CORPORATION, INI)I4rII)UAL. etc.)
<br /> 4. Check the appropriate box for TYPE )F BU SINESS.
<br /> 5, If Facility/Site is located within wt Indian reservation or other Indian trust lands, check the box marked "YE.S".
<br /> 6. Indicate the NUMBER of TANKS at this S"l'17.
<br /> 7. Record the E.P.A. ID # or write "Nt)NE" in the space provided.
<br /> H. PROPERTY OWNER INFORMA110N&ADDRESS (MUST BE COMPLE77D)
<br /> Complete all items in this section, unless all iters are the same as SEC,I'ION 1: if the same, write "SAME AS SI`IV r€,cs
<br /> this section. Be snare to check PROPERTY OWNERSHIP TYPE box.
<br /> III. TANK OWNER ENE'OI ATION &ADDRFSS (MUST BE COMPLE, VD)
<br /> Complete all items in this section, unless all items are the same as SECTION 1: If the same, write "SAME.AS StT7?" acr,,
<br /> this section. Be sure to check 7FANK OV1W.RMHP,TYPE box.
<br /> Ill. BOARD OF I't(?UAL17.AITON US-I'St'ORAGE FEE ACCOUNT NUMBER (MUST Bri CoMPE, na))
<br /> Enter vour Board of Equalization (13017) UST storage 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 rcporting the
<br /> $0,006 (b mills) per gallop fee daze on the number of gallons placed inyour USTs. The BOE: will code, persons exempt from
<br /> Paying the storage fee so returns will not be sent. If you do not have an account number with the BOZ' or if-you have any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOF at the following
<br /> Board of Equalization, Environmental fees Unit, P.O. Box 942879, Sacramento, CA 94279-0€101.
<br /> V. PETROI,E7UM UST FINANCIAL RE SPONSII3H n-Y ST B11 COMPLErI'ED)
<br /> Identify the method(s) used by the owner and/or operator in meeting; the Federal and State financial responsibility
<br /> tegturements. USI's owned by any Federal or State agency are exempt from this requirement.
<br /> VL LEGAL NO11FIC K..E1C)N AND R1I1,IN(i ADDRhS,S
<br /> Check ONE BOX for the address that will Lac used for Will LECIAL AND 1311,IJWo NO ITIrIC'.ATIONS.
<br /> APPLIC:ANF MUST'SIGN ANI) DNJE TlW FOR , ',Ayl(WI'ED.
<br /> IN41'RU(7rJON IIOR`I11E7 LOCAL AGENCIES,
<br /> The County ""Id jurisdiction numbers rs are }� ned sand can be :)btained by calling the State Board (916)739-242.1. The
<br /> facilia. nurnhwr fwiy be assigned b> the local agency; however, this number must be numerical and cannot contain any
<br /> alphabetical. If the loct0 agency t fens the State Board to assign the facility number, please leave it blank.
<br /> rI' IS TTII3 R PC);aa,Sl,IsEl.i`I'Y OF`I11H LOCM..AGENCY 'IT-IAT INSPIXTES 'TIIE FAC'IIXI'Y TO
<br /> VERIFY 111E
<br /> AC'CURAC'Y OF T'III INIAC) TION. ims APPLICATION CANNOT BE PROCESSED IF IIIE DOE:ACCOUNT
<br /> 1`IUMI BEM IS NOT I'i .:I) IN. `I1IE LOCAL AG1 C.Y IS R SPONSIBIA;, EUR IME COMPLEON OF 171E
<br /> "LOCAL AGENCY UST.; ONLYY' INFORMA110N BOX AND FOR FORWARDING ONE DORM °A"AND
<br /> ASSOCIA"I10 R)EZM '113'(s) TO 11IF E'OLIDWING ADDiENS,
<br /> SI'A'I`i•, OF CA 1FORNIA
<br /> 917VIT ' AIER RESOURCES _ N11tOI,BOARD
<br /> C./0
<br /> I),PVJA PROCES—SING CENmR
<br /> P.O. BOX 527
<br /> g _ MOUNI, C_
<br /> l 90723
<br /> 0
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