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-77� <br /> '75 . x� �7,, --T <br /> INSTRUCTIONS FOR COMPLETING FORM "A" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "A" shall be completed for all NEW PERMITS,:PERMIT CIIANGES or any FACILrTY/Srl7? <br /> INFORMATION CHANGES. <br /> 2. SUBMIT ONLY ONE(1) FORM "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 PERIMIT APPLICANT or the LOCAL AGENCY UNDFRGROUND <br /> TANK INSPECTOR. <br /> 4. Please type or print clearly all requested information. <br /> 5. Use a hard point writing instrument, you are making 3 copias. <br /> TOP OF FORM: "MARK ONLY ONE ITEM" <br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> L FACIIA'Y/SITE INFORMATION&ADDRESS(MUST BE COMPUnW) <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 NUMBERS ARE NOT ACCEPTABIM. <br /> Include nearest cross street and name of the operator. <br /> 2. Phone number 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 OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) <br /> 4. Check the appropriate box for TYPE OF BUSINESS. <br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". <br /> 6. Indicate the NUMBER of TANKS at this SITE. <br /> 7. Record the E.P.A. ID #t or write "NONE" in the space provided. <br /> H PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLE111D) <br /> Complete all items in this section, unless all items are the same as SECTION 1; if the same, write •SAME AS SII73" across <br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box. <br /> III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS SPIE' across <br /> this section. Be sure to check TANK OWNERSHIP TYPE box. <br /> IV. POARD OF EQUALTLATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPI.IL") <br /> Enter your Board of Equalization (BOE) 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 repotting the <br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The HOE will code persons exempt front <br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BOE or if you have any <br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address: <br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBII.ITY (MUST BE COMPIMED) <br /> P <br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility <br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement. <br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS <br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND AIDING NOTIFICATIONS <br /> APPLLCANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <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 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'111E RESPOIS,SIBII.ITY OF T1IE LOCAL AGENCY THAT INSPECls THE FACILITY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT <br /> NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE MR THE COMPLETION OF THE <br /> "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR PORWARDING ONE DORM "A"AND <br /> ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> ,STATE WATER RESOURCES CONTROL AQARD <br /> C/O SWEEPS. <br /> DATA PROCESSING CENTER <br /> P.O. BOX 527 <br /> PARAMOUNT, CA 90723 <br />