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<br /> (31i S- L INSrRUC`:610N,S:
<br /> 1. One FORM A"shall be cornpl tc.d fOr,all NEW P rl ,PERMY,H°CIIANf;iFor,any ICAC"IIXIY,ISr1T'.
<br /> 2. fitTBmn,ONLY ONE,(1) FORM W for a Facility'site; regardless of the number of tanks located at the site.
<br /> 3. This Coma should be cornpleied by either the P]t RNIU APPI C.AN'I`or-the LOCAL AGENCY UNDERGROUNDTANK
<br /> NSPI:C"I"£)IY.
<br /> 4j 'I'lcase type or paia,i clearly all rcqucstcd information.
<br /> 5, Use a hard point wri inn instt€mcmi,you are making 3 copies.
<br /> TOP OF IrC RM. 'MARK ONLY ONE111W
<br /> "
<br /> 1. Mack an(:X) in the box next to that item that hest describes the;reason the form is being completed,
<br /> I. FAC'ILI` /S I"I INI?OR `110N&ADDRIWS(h UI I; BE C OMPIZCUD)
<br /> 1. Record name and address(physical I€kation)of the underground tank(s):
<br /> .5`aC)'I`f?; Address MUSt'bav a valid physical location including city,state,and;rip aide. .
<br /> P.£).BOX NUMBER ARII We ACC UFFAIN
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number mast have an arca code. If the night number is the-saine,write "-SAME' in proper location.
<br /> 1 Check the approl,ritatc box fc)i-T Til 0It BUSlNIrSS 0WN3 iI_HIP(ex.CORPORATION, INDIVIDUAL, etc,)
<br /> $.
<br /> Check the appro , ate l'sox f<r`l't'llE =tI BUSINI.SS,
<br /> 5, If Facility/Site is located on land within an indian :reservation or otherindian trust tands,�_check the box marked'YES',
<br /> 6Indicate the ia,UTM1331,1Z ofTANKS at this
<br /> ?. Record the I`1,11,A. 11) # or write °;°CE)N] in the space pr(vided.
<br /> 11, PROPEWIN OWNUR INFORMNUON&ALS s( Il l' 1H CO PWII
<br /> 1. Complete all items,in this section, unless all i€cans are the same as SIX'110N 1; if the;same.write `SA If AS SCIt°acr€)ss
<br /> this section. Be sure to check PROPERTY (3` NU,"RSFIIP 1'YP box.
<br /> ..'IIS..I'ANK O NE"R INFORM +'17ON &ADDR SS 3 coma rm-D)
<br /> 1. Complete all stents in this section, unless,all items are the wine s SERI"I`I()N 1; If the same,write '. I:i AS 41`U"
<br /> across this section, Ba sure to check TANK C WNE SHIP"I"1 PE box.
<br /> I ntcr your Board or rxjuaiiz,ation (1310,',) U51'storage fcc ao:ount number which is zetimairvd before your permit ap�iictftion can
<br /> lae.processed Registr4ati€>n with ilii 10E wvbl ensure that you will receive a quarterly storage fee return in'reporting the,$0.f00, '.
<br /> (6 mills)per gallein fes;due on the nurx bei of gallons'pladed in your LSTs. The:BOF will code pczsons excntpt'fic;m eying the`
<br /> storage,fate sea returtas will not be sent. Ii'you do not have an account number with the;BOF or of you have any questions
<br /> regarding the fee or exp ntptioas, please call the BOE at 910-739_2582 or write to the BOE at the following address: Board of
<br /> Equalization, Fnvaroarnental fees Unit, PD. Box 942879,Sacramento, CA 94279-00,,07.
<br /> V I13C=AL NC7 'Ilat('A`HON AND 13IIJ ING ADDRP-S%
<br /> l_ CbeckONEBOX for the address that will be used for PAY111 1.T!GA�AND I3 I ,ING (YUJU `FIC)NS..
<br /> APPfJ(:A F U I`SIGN AND DA"l`E?`I lU 11()RM AS INI)I(WI ).
<br /> t �
<br /> INtiI'RUC'11ON IaOR'I'W LOCAL L ACAt' £'[S S
<br /> 'I"tae county and jurisdiction numbers,are predetermined and can be obtained by calling the State Board(916)739-2421. The
<br /> facility nurnber may be assigned by the loc<al agency, however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prelers the State Board to assign the facility number,please leave it blank.
<br /> II"I`s` dI"?IFIL IN:iII3Iid I fr ILII? i3f AI -N
<br /> C Y 71 IAI TtSPI C' S'I I[I?FAC111IN TO VERIn 11 IE
<br /> ACX- C� ()E'-11111 I�lfla"£)RMNI'I() , -1111S APPI,IC:A`t'IC)N£'Atd1 (Yr BE PROC�IISSED IIr 1111 Bot!AC'C,"C)L ler
<br /> NUMBER IS NUI'Ia1C.I10 IN. '111F E.C)('AL AGINGY IS RKSPC9NSIBUZ,FOR`TI 1 C:OMPL1?'[ION 0 8'171 ?"II)C:AL
<br /> AGENCY USE()N:l"FNI?ORM/VIION BOX AND FOR FORWARDING ONE MRM"A"AND ASS .,/ IED IUR
<br /> '13'(s)71'0 171F011,0WING ADDRESS
<br /> SiY./`l't3.C)It(.A I,IFORNIA
<br /> °A`I i W)VI R IIII.SOURC'IN U)NI`ROL BOARD
<br /> (d/()S-W.IIIEP-S.
<br /> DATA PROCE-SSING CINIMR
<br /> P.O.IX)X 527
<br /> PARAMOUN I7,CA%M3
<br /> e J
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