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GENERAL V.I'R1K`I70Ss
<br /> 1, One 1';CJRM"A"shall be completed for all NEW PERMrIN,PHRMT1'ClJANG0Sear any FACIIJI'Y/SrFE
<br /> 2.- SIJBMY1'K)NLY ONE(1)FO 'A"for a Facility/Site,regardless of the number of tanks located at the sitc.
<br /> 3,. 11iis form should tic completed by either the 111,1 lR i{1' PUC` N1'or the LOCAL AGENCY UNDERGROUND I"AN
<br /> NSP1iC;r0R-
<br /> 4, -phase type or print clearly all requested information,
<br /> S. Use a hard print writing instrunrent,you are making 3 copies.
<br /> 'FOP OF FORNE*MARK ONLY oNE rnw, *,
<br /> L Mark an X) in the liana'next to the item that best describes the reason the form is being completed,
<br /> L F C:RXI"Y"/SI"I t" I ) '1C) i&ADDRII&S(MUS17 BE <O MPIjuu))
<br /> 1, Record nanne and address(physical location)of the underground tank(s). '
<br /> Nffl13: Address MUSr hale a valid physical location including city,state,and zip code,
<br /> PCr IK)X NtJMBER AREN(YI'ACC17FATITIL
<br /> Include nearest cross streci and name of the operator.
<br /> 2. phone nunmbet acini have an area code, If the night nunther is the same,write:'SA<!E,"in proper locatis.m
<br /> i Qwck the appropriate box for°I'C'I'=;OV T3USINE,-SS OWNERSHIP(ex. C',LJRI'l)k;N ICON,INDIVI1:7t IAL,etc..)
<br /> 8. Check the appropriate box fcrr`1 YPF€ F FU aINES&
<br /> 5_ if rlcilhypsile is located on lanai within an iridian reservation or other indican trust lands,check the box marked 'Yfis"
<br /> 6Indicate the NUMB of 17,'NKS at ihis SRI,,"
<br /> 7. Record the E,PI A. ti3# or arite'NON°" in the space pmvided.
<br /> U. FROP WF C)WNI!, Fri) 1'lO ,ADV 1!sS(Musr
<br /> l.. Complete all items in this section, unless all items are the same as ST C'I10N ];,if the;same,write *SAMBAS SI"I p`across
<br /> this sections. 13-ware to check.11ROI F"RI ' CIWNE'RS1111 "I'YPE box.
<br /> 111.'IAN [)'rNER INItt)RMS11E int&ADDRESS ESS( USY 1313€'OMPI,F 1111))
<br /> L Complete to all hennas in this•section, unless all iterim.s
<br /> are the stamc as fSF C..I'[C?N I; If the same, write *SAME AS S117r,.
<br /> across this section, Besure to check'I'ANK,t)WTsSEkSi IP I YPH box.
<br /> TV 140,A )f) 1 17 I,IZA11 )i u,,Fr I C)II K3I?F ?I:l AC(n1JN-r 1 IM111?R ArFU,F BE t C) I�IE I)
<br /> atter your Ile and of Elxr.akzation BOT-) I `>1'st<mr°ale feu account number which is required before your permit application,can,
<br /> be proces,..wd. Registration with the FOEwilt ensure that you willreceive a quarterly storage fee return in,reporting ft!SO.QQ6
<br /> (&mills)per gallon feu due on the number of gallons placed in your UST's.'The BOE will code persons exempt from paying*the ,
<br /> storage feu so returns will not 1»sent. If you €o not have an account number with the BOF or if you have..any grmsfisons
<br /> rc,"rding the fee or exemptions,please cal[ the 130E at 910-734-2582 or write to the BOE atthe following address: Board of
<br /> I ciutaltration, F'nvironrnemal Fees Linn,P.0. Box 9428713,Stacrament«, C',A 14274-0001,
<br /> V. LI KI I,NuF'ImK:wI Oln AND I3ILLI CI ADDRESS
<br /> I, Check )INTI?BOX for the address that will be used for 30`111 I,FiGAL AND DILTING NO11FIQVIIQNS.
<br /> APP1 JC Nk'l1 MUSr SIGN AND I) ` Ft.°i 111;10118 AS INDICA 1°1).
<br /> iNs I°II:1; C FO FuOR`Ilff'?I,C)(:r L A' N2CIOS
<br /> `ne.eounty=.and)unsdiclion nrrmber~s are predetermined argil can be obtained by calling the=Stsate hoard (416)739- 2T. 'rhe
<br /> facility number may be.assigned by the local agency,however, this number must be num'crical and cannot contain an alphabet. If
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<br /> the local ragnmey prefers the State Board to assign the facility number,please leasee it blank.
<br /> rr iS°1'7110 III'-spoa$db 6F3II.,TF"t'otv, al WCAL AGE '1"11)V1'I SP13Ct' "17IF FrA UXI'Y'ro V13,R Irk")IE?
<br /> 1tC'URA Y t3IF 111 INItCk1 MAITOK '11IIS APP11CA'FIC3 £� C F"BE PROClI I I?fl "17113 I3C)E, ccot r
<br /> NUMBER FS wdr rI1.,u,,u) td, I'1§Fi LOCAL AGENCY IS RESPONSIBIlt FOR 111 CX) I"t ?I'It)T 011'111E'IfUCAL
<br /> ,
<br /> O1NC,'Y I J"A"I?ONLY'INIrC)RMNI'10N Il0X AND FOR FORWARDING ONE PO "A'AND A&q)(INMD FORM
<br /> °13"(s)'I 111 3 FOLLOWING€IL)I)I2ES
<br /> SEA173 014 C
<br /> ALWORNIA
<br /> C/o S.W> I � _
<br /> P.O.BOX 527
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