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<br /> E .i' I. �i`RDC7 NTS,
<br /> 1. One f"'OpNA "A" shat. be€ornpleted for all NEW PERWES, PERMITC11ANGES or'anc FACILITYJSt`II�.
<br /> SUBNa"1f ONLY E ('I) a M W for a Facility/She, regardless of the number of tanks lova lcd .al tl.�. . +r:.
<br /> W. f.o.- a St Iofd 1-re completed by either the 1'I;II.MIT AI'PLICANI`"or the LOC"AI,,AGEN(Y Ctis€I)I'.It61ZOtlNNI)
<br /> TAN
<br /> 4Please tape or print clearly all requested information,
<br /> 5, " Use a hard point writing instrument:, you are making 3 copies
<br /> y t
<br /> TOP OF FORIVU" * ARK ONLY ONE ITI ".,.
<br /> . ;An (;Xl in tht, box next- the item.that,best deser�zlaes the feasosi`t4tc�fos°gat"is-Iaeitt� er>n1pleted.
<br /> I. I At 1f.IT" ' STI`Ii
<br /> INIFORMAflON,&ADDRMS (MUFF Ilii C OMPIM11
<br /> z. Cccrord mare and address (physical location) of the underground tank(s).
<br /> O E: A ddews NIIJST have a valid physical location including eity, state; and rip code,
<br /> RO. BOX NUMBERS ARE N(Yr A ° :* I.1
<br /> Include nearest cross street and name of the.operator.
<br /> 2, phone nwrt er must hgv0%an rea cads. If the night number is the same, unitefSAN11:?" in proper location.
<br /> 3, Check the appropriate tok foo°TYPE O BUSINESS € WNERSHIP (ex. t;Ct�ti'CSRATIO , iND'l 'fI:)C.Aj,,,, atc.)
<br /> 4, Check the appropriate, box for"TYPE OF BUSINBSs.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian tract lands,clseck the box marked Pisa"
<br /> O. Indicate the NUIN3]3T R,of'IANKS"at this SI'I"I a r
<br /> ;a, Record tlrr L'.P.A.`Tl,) # or write "INLINE:" in the space provided:
<br /> 11. 1'IC(3I' "WI`Y O ?II INFORMA7.11ON &ADDREWS ( :ISI'BE C'MOLE T I I))
<br /> Complete all items in this section, braless all items are the same as SEC 11ON 1, if the same,write *SAME AS Sifi l,'" :aen)ss
<br /> this section, Be stare: to check I'Rf1F'ERI`Y OWNER,13i-HP ,TYPE box,
<br /> HL TANK OWNER,INI 3IT C a& DDRU&S (MU,51`1113 C:OMMI 1TD)
<br /> Complete all neons in this section, unless all items are The same as ,S ION 1; 1 the same, urit.d,"SAME"AS 4ITI7 a0,)'t!:
<br /> this section. Besureto check TANK OWNERSIflPtYPE box. `
<br /> IV., BOARD OF 1 i3AL'17WIION usr sror.AoE 1-TE A CfAiJNr NUMBER (MUS"'BE C`C) li-11.0)
<br /> Linter your Board of Equalization (BOE) 'UST storage fee account anumber which is required before your permit, application
<br /> can be processed, Registration with the BOB will ensure that you will receive a quarterly storage, lee return in reportin, the
<br /> 0,006 (d mills) per gallons fel~due on the number of,gallons placed in your USTs. The BOE will code pers(1ins eNkent rt."t rtarao
<br /> paving the storage fee so returns will r6t be sent. If you do not have an account number with the BOL or if ,'0€t ln�c l anv '
<br /> questions regardin; the fee or exemptions, plewse call the BOB at 916-323-9S55 or write to, the ,13013 at the following add,cs,s.
<br /> Board of Ujualization, Environmental pees Unit, P.O °Box 942379,Sacramento, CA t14�"r9-£�J416• "
<br /> " rnu)f-ruw usr FiNANciAL Ri3spoNsiBuXIT ( OSr BE CO NTai
<br /> Identify the mmethod(s) used by the owner and/or r operator in meeting the.Federal and State financial responsibility
<br /> requirements. US"I's owned by any Federal or State agency are exempt from this requirement.,
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<br /> Check ONT.BOX for the address that will be used for I3CTpH TEGAL AND BHJJNG N(Y17 rIC:A"HONS:
<br /> AppijcANr MUlzMSIGN AND DA111711E,FORM AS INDICA1111),
<br /> si`RU 310 FOR°L`Hi LOCAL AC"FNC.ES
<br /> 'rhe county and jurisdiction numbers are predetermined and can be obtained by calling the State Lenard (916)739-2421, The
<br /> facility number may he 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 1111z RESPONS11311XIT OF WE LOCAL AGE C`Y TEAT INSPEC' 'I I?FAGLrIY TO VERWY 1111",
<br /> AC'(,'U (,'Y OF THE Ib FOR A`I`ON. T S AI PLICN TON 'BE PR C"ESSED III `HE I' ACCOUNI,
<br /> NUM1*R iS Nar FILLED IM 111E LOCAL AGENCY IS IISPO .SI f 1 1 , OM'PIJ"T'IC31� F 1j1Z%
<br /> 'LOCAL AGF C"Y ISS?ONLY* Ibt'La l N.110� FOR 1 12" TANG ONE R `"A" A
<br /> ASSOCINIED FOR 'B'(s)TO THE F()LLO T CI A Iy YLsi.:
<br /> 91'All!OF CATIFOR Irk
<br /> (./cl & .Iq T"
<br /> DATA PROCESSING CENIER
<br /> P.O. BOX 527
<br /> PARAMOU.Mr, CA 90723
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