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<br /> IMSFR.Z.1MxON.S FOR ('CiMPe a�.:S°FI NG OR 'A'
<br /> be co rnpleted for all NEW PI? fit , PE.I2 LIFT'MA CILS or any FAC 1I,TpYfSfl`
<br /> ' I�� Sa.I�LA"h1C3:�i C'fTA7�1€:Is. ,
<br /> 2. S'il 3Fe O'ONLY ONE (1) FORM "A" for a t acihty/Site, regardless of the nunttacr of tanks located at !,Yi, stta..
<br /> 3, °mitis foritt shn"ald be completed by either the 11FRMI'T APP11CANF or the Lflt:AL AGENCY U'4T3I.IZfsIZ(3UND
<br /> "TANK ISISPEsC"I'C)Z
<br /> r Inert clearly all requested information.
<br /> �ml writing instrument, you are making 3 copies.
<br /> . , —K ONLY OINIF,ITF34" z
<br /> rl: an (X) in the box next to the item that 'best describes the reason the form is being eossspletec9.
<br /> L 1._,_L,I<,3 I'Y/ST'I°E3 I I IR CIN&ADDR 3,`S ( US17 BE C ?M P LT'E17?33)
<br /> i. Record`statue and address (physical location) of the underground tank(s).
<br /> NOTE: Address MUST have a t-alid physical location including city, stake, and zip codc,
<br /> V.0, FICIN NUMBERS ARE CII'ACyC IEFI' 113-
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number mint have an area code, If the might number is the same, Waite "°SAMI " in proper location.
<br /> 3. Check the appropi ate ttaox fear`I YPE OF BUSINESS C>y NIHIRSHIP (ex. COIIPORLATION, fNIJlVIDL AL. etc)
<br /> 4. Check the appropriate box for"TYPE, OFF BUSINESS.
<br /> 5, If Teacility/Site is located within an Indican reservation or other Indian trust leads. check tivc box marked YES",
<br /> 6. , Indicate the 34LC3.tBER of TANKS at this SITE
<br /> 7, Record the E>,L".A. I17 # or write `ty<3NE",in the space provided, t
<br /> II. PROPS I"Y OWNS I K)R A'I"IC7 1&AI:DR S (MUST BE C-OMPI.. "E`FD)
<br /> Complete all items in this section, unless all items are the same as SECII'ION 1: if the saniewritc "SAIME AS SFI T", rrbcs
<br /> this section. Be sure to check ROPT,-T 'Y OWNFIRSHIP TYPE box,
<br /> HE rAY9NK OWNF,Z W FOR A LTO AT I REsN z cO PLI 110)
<br /> Complete all items in this section, unless all items aixc the same as SEC°ITON 1, If the same, write "SAME,AS S6 t"1, ac r ss
<br /> this section, Be cure; to check 'IA C) Era SHIPt: .PI;box.
<br /> IV. BOARD OF KB IMV.17IO LJST S`T'0RA(3E ME A(C:`C1UMI' BER (MU5r III.' (XMJP-1"TD
<br /> 1'tter your Board of Fxjuafizaiion (BOE) UST,storage fee account number which is required before your perntit application
<br /> can be processed. Registralion with the BOB trill ensure that you will receive a quarterly storage fee, return in reporting the
<br /> $0,006 (6 mills) per gallon fee due on the number of gallon:, placed iny)ur USTs, The BOE will aide persons exetnin from
<br /> :paying tate storage fee so returns vrll not be scan. If you do not have an account number with the I301,' or r,.yoh,havc'atot
<br /> questions regarding the fee or exemptions, please: call the; 130E at 916-323-9,555 or write, to the 1401' at the followin1g, ;,Id i.cs.
<br /> Board of Equalization, Enviro22TYmtts.kal Fees Unn, RO, Box 942979, Sacramento, C'r'y 9,1274-MAL,
<br /> V. l"I3°I° 7t IJP`FINANCIAL P ISSIB11XrY (MUS"7"B11 CX I,1z1E.1"E ))
<br /> Identity the method(s) used by tate owner and/or operator in meeting the Federal and State financial responsibility
<br /> rcquiremenrs. L',STs owned be arty Federal or State agency are evenmpt front this requirement,
<br /> L JUGAL.N(Y1T€r CA`I1 N AND BI LING ADDRE&S
<br /> Check ONE 13Ofor the address that will be used for B0111 LEGAL AND 13111 NC; N017tI C'AI'IONISS
<br /> APT111CAMF 3,LTSr SIGN ANIS L3XM'171E FORM AS INDICAT1411
<br /> INS" UC ION FOR'111E,LWAL AGENCIES
<br /> The county and jurisdiction numbers are; p,edeter°ntined and can be obtained by calling the State Board (91(i)739-2421, The
<br /> facility number may be assigned by the local agency, hoxvever, this number-must be numerical and cannot conwin any
<br /> alphaileticaL If tr e local agency pre en the State board to assign the facility number, please Leave it blank.
<br /> ri, is` a," R1 S ISIBILYI'Y O "M E LOCAL ACII N(.Y 'I'TIA'F INSP?.CTI THE,kaAC;1XIT TO VERIFY 11W
<br /> ACCURACY Y CIIF'I HE INIFOR 'I10 . `1111S APPIK `I"C)N C°.AIdN(Yl' BE PROCESSED ESSED Ta THE WE AC'C'C)EFMF
<br /> UMB1" S I FILI ED EN. `111£L LOCALA II C Y I RE-S"PONSIBI T? R °17IR PL ITnON CEI;`'III?
<br /> "LCI A x A ENC" USE ONLY" INFO n W3 ,A FOR FORWARDING ONII4NAM "A"AND
<br /> ASSOC1It`S'1'I=D 1 ORUTA '13"(s) TO THE' IF031J,() Tx . ,1't RESTS.
<br /> STNI V,OF CALIFORNIA
<br /> ORNIA
<br /> 31WIT i N113R fiL S0! ILC L S a; Irl ROT. BOARD
<br /> DAXA T"ROC'F SING, CT CI R
<br /> P,C3_ BOX 527
<br />
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