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I SM C31ONS IUR C O Marl.irING I y *A
<br /> GENERAL IN',L;J'RUO1T0NR
<br /> 1. One ext.:>R "A" shall bo cornpl€ted for all NEW PEMMITS, P17IitMIT HANG .3s =".^sCILI Y/S41U,
<br /> " SUISMI t° 8 ONE (I) I )RM *r for to 1 ailttrJS€te, n,,;aardl soe' lb,u t uln
<br /> a Ss felt r be coanpleie€t by either the ["� E� Ii"1 B'I�1aB ��II �r Clic LOC AJ, AOFINICY IMA
<br /> TANK INSPEUTOR.
<br /> 4, Please type or print cicariy all requested information,
<br /> 5_ Use, a bard point writing insar°ome n4, Srou are nnakim, 3 c pic'.
<br /> `'I`OP 317 FORM INNIARK ONLkv ONE t1 .; `
<br /> k an (X) in the box next to the item that best deecrif;es iste reason ihe form is h inn coiuf,teated.
<br /> I= CS°lI,B1'r' s BzINIMMKILION&ADDRE&S ( usr In, ;C) 1I'Is rrFilO
<br /> 1. Record name and address (physical locatticm)_of ilie undergrnurnd rarnkis=.
<br /> :";OTE,: Address`SII,s l" have a valid physical location including E?y, state. and ..ap y.,dc=
<br /> X0. BOX NUMBERS ARE N(Yr AMUTABUL
<br /> Include nearest truss street and name of the operator.
<br /> 2. Phone number must have an area code, If the night number is the sante, write 'ANAP in p €ipc r kxat�iors.
<br /> 3, Glick the appropriate bbi'for TYPE OF BUSIN SSOWNF CSHI' (ex, C;C7ICI'ORA" ON. cic:.)
<br /> 4, Check the.appropriate box.for TYPE OF BUSINESS.
<br /> 5, If Iacifityf ite is located veithin an Indian reservation or ether Makintrust !ands; check the box niark,cd E::=
<br /> 6, Indicate the NUMBER of'TANKS at this srra
<br /> 7. Record the ERA, ID # or write 'NONE" in the space provided.
<br /> IL PROPERIT OWNER 1"C) I-IO BSB RUSS ( US`F BF C;C) I$I U MD)
<br /> Complete all items in this section, unless ;all items are the same as Sl>C,l'It)N #. if the sem r, wrlies 'SAME,AS ;r1 V,`
<br /> this section, Be scare to check I'12.C.P I2"I" CS` i4ER-Sulip•I,yt"I:, Ilex.
<br /> Complete all items fit this section, unless all items are the same, as 1: It the swne." ,triie 'SAN4,:=:AS Kf1°l^r
<br /> this section. Be,sure to check 37ANK OWNERSHIVITIT bo
<br /> . i3oARD t F 1povAjqAnoN usr FOR E?IrE.s`E £,C")ITNr 7sfumtot BSn III=, colvi IB nla))
<br /> Enter your Board of Equalization (BOE) L;ST storage fee account eraarraber whi=ch ir4 required he Cowe yca,rr f°es.>'r 3tY <;}rflicd,tar�rt
<br /> can be processed, Registration with the BOE will erasure that you wifl re€reign a quarte tyr mor a c ?;;u !.,, .r:, in a..r, r.,..ing e),.c
<br /> $0,006 (6 stills) per gallons fee due on o n the number of gallons placed in your U917s. The 130E will codc, a.i.•c E;t a.,.:.rf. .a<)nn
<br /> pzyira the storage fee uses returns will not be sent. If you do not have an account nutilber illi Ste B01`,.', csr�' e�if mu have any
<br /> questions regarding the fee or exerrnptions, please call the BOE at 916-323-955,5 or write to the 130E at the; following
<br /> Board of Equalization, E mironrrsewal Faces Unit, r.t). Box 942579, Sacramento, CA 94279-0001,
<br /> V. IIHFROUUM LISF FINANCIAL RESPO S U SIT (M 1'Be, ;c B. ;I )
<br /> Identify the method(s) used by the owner and/or operator in r=teef ng the Federal tenni State financial r c%f onsibil;ty
<br /> requirements, USS"1"s c v ned l;y any Federal or State agency are exempt from this reel air.niwnt.
<br /> LEGAL NKYI1"(W11ON AND EI1MING ADDRENS
<br /> Check O ?BOX for the address that will be used for B611I LEGAL AND 11111ING NCY11MCA11ONS.
<br /> APPTICAMF B S"1'AIGN AND D/Of °I t;MRM AS INDI ,II'I'B T).
<br /> The county and jurisdiction numbers are prede°ten pined and can be obtained by calling the State llrazr d (916)739-242l. The
<br /> facility number may be a,%igned by the local agency; however, this number raust be numarica` ,hoes ainirsir r.otit ai r ani,
<br /> alphabetical. If`the local agency prefers the State Board to assign the facility number, please leave it blank,
<br /> I"E'IS"fill, RRSPOM1811HY OF 171E LOCAL I I Cr '174A,11'INSPI 'I"S"B"BII;FACH11Y TO VERIFY2II,.
<br /> ACCURAC'Y OF"BIM IIB RMNITO > 111155 APPLIC;' `T"ION C'AaNNUF BII; FTZ0C;IaSSI,I IF`11111,I Ii: a CC;t)C..lN'
<br /> f.1 111I S N(Yr IAB TED Ili, 'ITIS LOCAL tI INM IS ECI=°WO SSII 1,a FOR 1"EIfBi ,CSFB I"ION CSI.=,"1111?
<br /> 1,0C.;1 L AGENCY Y USE, C) I " II FORME TIti N WX ANY)II) FOR FORWARDING ONE FOR 'A' AND
<br /> SSOCNM10 FO W(s)TO'I't HE F011,01hfIFRI ShS.
<br /> ' IAI : OF CA II ORb,, k
<br /> P.O. BOX 527
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