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<br /> 1- On. I'OR l A" slaall be rwonlpi£ted for all NEW VEBmrrs, PERm'C' CHANGES or €ny FACIt ITY/S]TV
<br /> I IN,AZ a`t'"I`ON C ANG ES
<br /> S 11 4I`C C1NLY ONE(1) FORM "A" for as l .��htl�l.lite, reg,�trdlrss of the au4-ib r of larks located tit :the . f..
<br /> I, '.Iia: fiat sfc;ett ,, cettt,l,l<.tcct lay c.at¢v, aIle tl.Rmr1' i` [C Nr or dic T,6C.Al, GFNCY Ell\;i)I,ICdtif
<br /> 4K INSPPA"11)R,
<br /> t. CSI£"ase type,, or print i1early ail .Nr,Auestc,"d inforl.la6ott
<br /> hard po is n ae'ng ;;.�s.n,;,r, ;it are r tGat:ng 3 c€rizc .
<br /> 1Y)POIlFOR41'. 'MARK ONLY ONF!, cllA'
<br /> Matt an (-E) in ibe t>r,.r rest to the f eni that beat describes the reason the form is lscing compleael.
<br /> I, Ir C H11-``SFIT, -C IC; 110N & ADD II&S TC;ISI' EI C OMPLrs`ITD)
<br /> I, Record name and address (physical al s,catioN of the underground tank(s),
<br /> ;v011F'. Address MUST have a valid fahysi£'al lova icn includingcity, state; and Zip code.
<br /> .C3, 1`K)X NUM13EFCS ARE 4"I° CC FrAB
<br /> Include nearest cross street and .f<rrac of the operator.
<br /> a. n he3ne nurn e,r r.?-. sl, have an ,area, ctt:dc1 of Ill,-9 3,iight ,runnier , t:e s am,,, write S AN4F." in pronor loci ztion.
<br /> 3, Check the ap prgt,r a e box for "I'N_, OF Bt'_JSI:e" S$ OWNERSHIP (t;x C;C)RPOR 'If10 , INDIVIDUAL ic.)
<br /> 4, Check, the appropriate b(,,lx for TYPE 01' BUSINE,S&
<br /> If r"acilit,/Site is. to cated wiihia an, Indian reselv,ation or other Indian trusthands, check the box marked YES",
<br /> C:. €radlca e the NUMBER A BER a,t 't,"tNKS at this y11'I`fa,
<br /> Vie£ sd >hc :°t, t, A,r rasa+,c.,"N, ea th�, vlac p_wide 1.
<br /> 11.. §"��.PIE'IZI l0r,,W 11i TNIatl,"R NON �133t x� (..13I�'I' 111' C;fI ISI tal3xl3)
<br /> =l t all items in this section, 3t.alcss all ft n-ts are the sa>rne as `ICTION l; if the :lariat,, write "SAM';AS S1`I'3;�
<br /> this section, Be sure tea check PROPER'IN fl° Nf.MS111I' TYPE Brix.
<br /> III. °TAINK OWNER FNF01I /1,,l IC"1sN a= r)1IIv1 SS (IvILISI` 13E C OMPL lITD)
<br /> ,4brn: lcct all fteYIIs E:C:', this FC.£...iC t6 unless al, ita.P'0.";,s a„+„
<br /> ;lie wine as &eECI'10N 1; If the siirnc, wcute. *SAME" AS srn,,, <;E cess
<br /> th?,. sects :r. Be wereto check TANK () iss3 RSHIP1WI`,. tiox,
<br /> IV" OAK[) O (X,)TJ LJZ,., ._J'0N @.STI 'CI yrC,l. I"1:13 AC"I"C'IUN`I' M- 1311 ( C I"BE .WP. 171))
<br /> Enter soar Board of Fgta,alizat on (lst:tE) 1;4'I' storage fee account number which 1s required before your p r tit ,,plilicmicli
<br /> can to, processed. Registration v4th tire BOB will ensure that you will receive a quarterly stowage tee return in mpttttin,g the:
<br /> $0,006 (d mills) per gallon fee due on, the number of gallons placed in your C.7,51's, The BOE will code persons exempt ftzaraa
<br /> paying the storage fee so returns will not be semi,. If you (to not have an account number with the IOEI or if you have any
<br /> rluestions regarding the fee or exemptions, please call the DOE,at 916-323-9SS5 or write to the BOB at the following ,afar{„s:
<br /> Board of Equalization, Environmental Fees Unit, P,O, Box 942379, Sacramento, CA 94279-0001..
<br /> VP17ROL, II I CT,51'FINANCIAL'13 P03BTrY I "3'R,11 C:O171
<br /> I enfify the arrcthod(s) used be tat owner awes/or operator in meeting tate federal and State financial responsibility
<br /> rtairm ments, L S 1's owned by any Federal or State agency are exempt front this requirement,
<br /> YT,,G L=NNO71f1I3IC TIC) ANIS 1311.)I CCaItl.:tl ESS
<br /> t:h k ONIF, BOX for the address that will] he need for BGFH LMAL AND B1UJNGN(Y1T1qCWP1()NS.
<br /> PPTaIC ASL”MUS-l'SIGN ANT) DA'1 1 11113 JlORlvl AS LI'3ILICN1 31).
<br /> I S'L' I.7C7 FOR 111E L, C AIA AfffiNCIEN
<br /> The county, ratios jurisdiction, nulrtfic s are p e.deternirne d and can be obtained by calling the State Board (916)739-2421. `I'Jte
<br /> aa,ilf or nu€xaber eery he assigned by the ;local agency, holy ver, this number must be numerical and cannot contain any
<br /> a,frl,a':,etical. If the laac»al agency prefers, the Star-, Hoard to assign the facility number, please leaven blank,
<br /> IT IS THE III NFONS"1I3II..I`IN' O '111,11 LOCAL A(]JI'lPICY 1711AT SPE(TI'S 17111 1 C'R TI"Y TO a Y°I LII°m
<br /> A(VURACY OF"['ITL, INPORMA310M 11115 PPLrI 'A`I:`ON CANNOT BE PR COSSET) r'"1 E 13011ACC01I '1`
<br /> Nt.1Iv111I:I:C LS t�a'OT FILLED IN. `1`HE LOCAL AGENCY IS RISPONSIBIE FOk 11111i COMPLENJON 0I7""Ii x
<br /> 'L,()C aAGENCY USE IITLLY* ilFoRNisnopi Box AND FOR `O INCE ON[I 1 I71 ' "MD
<br /> Sf) ;WFED l ). "It-i's)TO 'ITII FOLLOWING L
<br /> OF CA11FORNIA
<br /> rc,10 Ls. .t1tmLas.
<br /> P,CI,-Ilt)X 527
<br /> E_ C11, CA 90723
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