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INS`I'RU `UON,S FOR COMPLIA0,DORM-A-
<br /> GENFRAL INS-FRUGnONS:
<br /> L One FORM"A"sliall be completed for all NEW PERhTrl`S,PERM171'ClIANGES or any FACM-rrypsirru
<br /> INFORM)VFION CHANGES.
<br /> 1 SL BMJ`F ONLY ONE (1)IX)RM*A*for a Facility/Site, regardless of the number of tanks located at the site,
<br /> 3. This form should be completed by,either the P13RMIT APPLICAN17 or the LOCAL AGEN `Y UNDEMOROUNDTANK
<br /> INSPFk.I'OR-
<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 ONE rllW*
<br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed,
<br /> 1. FACIIII-Y/SnT,INIk)RMA11ON&ADDRESS*(Mult BF,a) li-IED)
<br /> 1. 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 ART!NOT ACIA1111—
<br /> Includenearest cross'street and name of the operator.
<br /> 1 Phone number must have an area code. If the night number is the same,write "SAME" in proper location.
<br /> 3. Check the appropriate 130K for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL,etc.)
<br /> 4. Check the appropriate box for TYPE OF BUSINENS.
<br /> 5. If Facility/Sitc is located on,land within an indian reservation or other indian trust lands, check the box marked lyl-I'S".
<br /> & Indicate the NUMBER of TANKS at this SITE
<br /> 7. Record the E.P.A. 11) # or write"NONF," in the space provided,
<br /> IL PROPEWIY OWNER INFORM/,.'[ION&AI))RES(MUSS BE CC)MPIII�I-L?D)
<br /> Complete all items in this section, uniess all items are the same asSEC.710N 1: if thesame,write PSAME AS SY1M.,'across,
<br /> ,his section.Ake sure v -heck PROPERTY OWNFRSHIPTYPE box,
<br /> III.TANK OWNF,R INUORMA171ON &ADDRI_%%(MUST"BY,"COMPJJn7 D)
<br /> L Complete all items in this section, unless all items are the same as SI_KTION 1; If the&,une,write ',SAME AS "I`E"
<br /> across this section. Be sure to check TANK OWNERSITIP'l-YPE box.
<br /> IV BOARD OF M. UAI.IZK1ION U51',51'ORAGE 11M ACCOUNI'NUMBER(MU SI'111COMPIKllff))•
<br /> Enter vour.&)ard of&laaR,,.a6on (Boi,,,) usi- fee account number which is required before your permit application can
<br /> be processed. Registration with Rhe 1`1017 will ensure that you will receive a quarterly storage fee return in,rcporting theS(1W).
<br /> (0 mills)per galloft'jec due on the number of gallons placed in your USTIs. -17he BOF-wrill Code persons exempt from paying the
<br /> c sc�vnurnswilfl nol be sent. If you do not have an account n urnher with the 1301"or if v-)u have aft qucstlons,
<br /> storage fe s Y
<br /> regarding the fee or cxcnrp�io-,us, Please Cal I i the 130)1_1 at 916-739-2582 or wfitc tea the 13017 at the following address: Board of
<br /> Equalization, Environmental Fccs Unit, P.0, Box 9422,871,Sacramento, CA 942794W.11.
<br /> V. IJ.X3AI,N(TUI?R:A'II0N ANI)IIHJJN(;ADDRE&S
<br /> I. Check ONE IX)X for the address that will be used for B(YI`TI 11XIAL A ND 13111,ING NWIFICATIONS.
<br /> APPL101NI'MUS17 SIGN ANT)DJV17?11111,FORM AS INDICA71ED.
<br /> IN517JUXT]ION MR 11111 LO(AL AGENCIII-S
<br /> The County and jurisdiction nLebbe rs are predetermined and can be obtained by calling the State Board (916)739-2,121. 'the
<br /> facility number 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 Stole Board to assign the facility number,please leave it'blank.
<br /> rr IS31113 RESPONS11111,1`17Y 017111B IX)CAL AGENCY 111A717 INSPECMIIIE FAC1IT1Y'I7O VERIFY'1711E
<br /> ACCURACY OFIIIE INFOR."AA7110N. "ITS APPIKAVION CANNCfr BE I1R0CF_SS1,D IFTHE BOH ACCP.UM.
<br /> NUMBER IS N0`F JILLED IN. THE LOCAL AGENCY IS RFSPONSIBIE FORIIIE COMPIJ?HON OFTIIE'I.O(:AI,
<br /> AGENCY USE ONLY'INIX)RMNYION flOX AND FOR FORWARDING ONE K)RM'A'AND ASSOCIA7.110 FORM
<br /> "W(s)TOTIIE FOIJCWING ADDRES&
<br /> EFIVIE OF CALIFORNIA
<br /> STNI'li WtVI`ER RE_SOURa_�N CONFROL BOARD
<br /> C/O s.W.I.uT_P.S,
<br /> DNI'A PR(X'f4SSIN(;CEMIER
<br /> P.O.BOX 527
<br /> PARAMOI NI,CA WM
<br />
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