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JNS1`IWC.1"I0l1S FOR C.'t.iMl'T,i'MING I�`XR W
<br />GENERAL
<br />i, Onc f "_s:in 4 ,ilia,, ,,,, for all NEW MiRMYRte 'PERMITCHANGEN or anY FAC"II,I I"Y /SIT ,
<br />u
<br />2, SUBA41 , trNLY ONE (I) 1,Y)R r1 't3 t, r a$ ? .,cs.,tY/Silc., regardless of the nusr,,,t.a lar ui: i,,
<br />]tis foo, h st3{,,, d be Completed by either the I'll RM.I r ' AM JC—AN ° or the LOCAL AGENCY a'1NDl,/'RGlbs r(;'alt
<br />TANK 13fSPEC;171C
<br />4, Please t)Te or past clearly all .rec)uestt.rl informatriaxt.
<br />S. Use a hard point wrilin; hltrnment, you are making 3 copies,'
<br />k ,,an (X) in .th<� next to the item that ]Zest describes the reason the form is. tieing Con it vt€~
<br />I. FAC 11111 ,,/,1 1, 1NF0RMXF1QN & ADDR&SS (,MUI; ` BE, C:C MPLIMIJ))
<br />1, Record name and atic3r s (physical location) of the underground tank(s).
<br />N01' : Address MUST have a valid physical location including city. state, aitci zip code.
<br />P.O. BOX jWMBEWS ARE O(F CC3; " B11
<br />Include nearest cross street and name of the operator.
<br />2. Phorte number must have, an area cock. If the night number is the same, write "SAMI " in proper loc•altoll.
<br />-3. Check the appropriate box for 'LYPI? OF BUSINESS OWNERSHIP (ex, C,ttIEPO '1"` 0N, iNDIVItiLAl., Cie,)
<br />4, Check theappropriatebox for TYPE OF BUSINESS.
<br />5, If hacilifySne is located within an .Indian reservation or other Indian trust lands, check the box narked "YCS"
<br />Cs.Indicate the ;''lUTNIBER of TANKS at this Srrl-,,
<br />Record the E,p�A, 11) # or`wnte "NO'sO' in the space provided, ,
<br />IL PR(..')I'I11I`I'Y OWNER INIMMATION & ADDROSS (MU S1- ilt? CoMPIA-a :1t))
<br />t,€ niplele sit itealts its this, 'e tsott, urticss €a1i items are the same as SEC",I'If)`"i" 1; if the lain, slide *SAMEAS > S HE
<br />this section, Tie scare r€s check PROPERTY OWk>ERSHIP TYPE"brix.
<br />III. TANK WNER ILII°Clic, ..,t."IC r " & ADDRUSS BE C OMPLIMED)
<br />COnIplete al: items ill this section, unless all heats are the same as S17-,CI'IO ]„ If the same, write "` Lit AS ,Srl`W across
<br />this section. Be sure to check 'I` NK OWNEWSHIVITPE box.
<br />ISA "ROA 21 1E%a UALI-° I:ICON UST' 9FORAGE FII1:1 C;C"C1i MI' NUMBER U,5F' F COMP �:-WE14
<br />Enter your Board of Equalization (DOE,) UST storage fee account number which is required before yoar peratrt application
<br />can lit: processed, Registration with the BOE will ensure that you will receive as quarterly st>z ,, fee ,ciu , in ,cpo tirZ;; gli
<br />�t?,ia 6 (C, mills) per gallon fee ileac on the nulliber of gallons placed in Tour i.51s: The BOF will ,;€d mn'son s <a:f)pt fl,om
<br />Saying file storage fee so rag=a=s will not be saint, if yore do not have an account number with the IIC31> =:sa i# out ha <ar y
<br />questions regarding the fee or exemptions, prase call the 1I0i; at 916-323-1655 or write to the 130t,"at Eliefs)�r<ttarrz`t articirasl;s
<br />Board of i(l ,izatka-Ena,irk�ri sent Fees Unit, P,O, Box 942g7<), Sactratterttst,-CA 94 7�-01)I1,
<br />r ', r "" NAN(I I. RESPOEI 11,I`7'Y (Must, EIII CIC➢I4 I' .Inl,,1 )
<br />Identify the tnethcai(s) used by the onvrier and/or operator in meeting the Federal and ;State financial responsibility
<br />requirements, USTc owned by any Federal or State agency are exempt from this recluireatsent.
<br />1. LEGAL ING11MWIJON AND IIIUJNG ADDREM
<br />Cheryl~ ONE BOX for the address that will be used for 1#C~iTH 11MAL AND B111ING MY1114 : °4"tC9sN S.
<br />PI,I °: I' X111#r STQN AND I lt`7'I:*. '1111B FORM AS IN Ca rl .
<br />IMSTRUEMION FOR THE TA)CAL,&GYMMS4
<br />The county and jurisdiction nut fibers ate predetermined and can be obtained by calling the State Board (916)739-2421, The
<br />facility € aztx leer may be assigned by the local ag
<br />pnicy however, this number must lie numerical and cannot contain an
<br />alphalletical, If tile local agency prefer. the ;State Board to assi-11 the facility number, r, please teaser it Sal;ask.
<br />D' IS'11111 RIMS )ytSJR11XI OF IME l Q)t;1AL A C I " '111AT ENS11,olS 111E FACH11Y TO VERIFY `ILII;
<br />a C;C;'I C;'Y Clic 11111 1°°ORMI .FION, THIS APPLICKnON DAiNdT HE TROC �5SE, IF "HIE JIM,' C:COuNn'
<br />NUMBIIC 1S Ct"' FILLED IN, THE 1. '1am 1. 61 C."Y tS RESPONSIBLE IKYR 1111 gQMPl.tlsl10,d oil? TIM,
<br />LOCAL AC11 NC."`I USE ONLY" INFORIVIA'FlObf BOX AND FOR DING ON11 iITOR 'A," AND
<br />AS.SOC7XJTI FORM ' (u) °r 1IIF 1roI,j e3Ws a' ls.
<br />f Il E< OF A II ORM
<br />SEATE W 1 . `,, ",,0qFR0L MARD
<br />rCIW.E°.S..
<br />"' EI CI SS�C1 C" ^ IL
<br />P.O, BOX 527
<br />PARAMOUNF, C°. 90723
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