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H.
<br /> lNS1RUC'nON,S' '-'X COMPLEIING IT)RMW
<br /> GENERAL lN5t'.,, �"'IONS:
<br /> "A' ,hall be completed for all NEW PERMHS., PERMrr CILANGF3S or any FACILWY/srW
<br /> --TIANGES,
<br /> 2,
<br /> CNH(1) 1k)RM 'A' for a Facility/Site,regardless of the number of tanks located at 111C slle
<br /> 3. 1` ° completed by either the WRTWIT APPI1CANF or the LOCAL.AGENCY UND171WROUIND
<br /> 4. Please t clearly all requested information.
<br /> S. Use a hard point writing instrument, you are making 3 copies.
<br /> TOP OF FORAC "MARE; C)NLY ONE ITEM'
<br /> Mark an (X) in -,�e box next to the item that best describes the reason the form is being completed.
<br /> 1. FACIUI-Y/SM,.1NJ-,,)1tN4A1 1aN & ADDR11-SS (MUST BE COMPLMFb)
<br /> 1. Record name and address (physical location) of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. 13OX NUMBERS ARE NO`1.`ACCliFFABIEL
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must haye an area code. If the night number is the same, write "SAME" in proper localion,
<br /> 1 Check the appropriate 1 )x for TYPE 017 BUSINESS OWNERSHIP (ex. CORPORA'IION, INDIVIDUAL, etc.)
<br /> 4. Check the appropriate box for TYPE OF BUSINFSS,
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands,.check the box marked "YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> T Record the E.P.A. ID # or write "NONE" in the space provided.
<br /> H. PROPERTY OWNER 1W0P1,AYA'170N&ADDRP-% (MUST BE COMPLEM,
<br /> Complete all items i-. € unless all items are the same as SECIION 1; if the same, write 'SAMI.; AS Sr]1,*
<br /> this section. Be m- _cck PROPERTY OWNERSHIP TYPE box.
<br /> Ill. TANK OWNER MORNLA,:IION & ADDRESS (MUST BE COMPLL31))
<br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME AS SITE" across'
<br /> this section. Be sure to check TANK 0WNFY,1URP'1'YPF box.
<br /> Iv. BOARD OF EQUAlfizxrION USI`SPO RAGE FFE ACCOUNT NUMBER(musT BE compunim)
<br /> Enter your Board of Equalization (BOF) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons ns exempt from
<br /> paying the storage fee so returns will not he sent. If you do not have an account number wit4 the 130F,
<br /> or if.Vou have-ally
<br /> questions regarding the.fee or exemptions, please call the BOE at 916-32.3-9555 or write to the following address:
<br /> Board of Equalization, Emrironmental Fees T"In;f, P-0. Box 942879, Sacramento, CA 94279-000L
<br /> V. PP,'fROIYUM USW IHNA,jCJAL ('MUS-F BE COMPIHIED)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> VL IlKiAL N(Y1111CATION AND B111ING3,ADDRESS
<br /> Check ONE, BOX for the address that will be used for B(TI'll IMGAL AND BIHING N011FICATIONS.
<br /> APIP ANT MUST SIG*AND DA-117 WE FORM AS INDI(wrED.
<br /> FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers arc predetermined and can be obtained by calling the State Board (91.6)739-2421. The
<br /> facility number may be 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 TTW V1111"SPONSIBUXI'y OF :-AL AGENCY TIMT INSPECTS*11W FAC II-M TO VFRB1Y'171F,
<br /> .;e AC,- uF HIP,INFORM/Vfl=, :,US APPIJCA'nON CANNOT BE PROCESSED IF ITIF Boll ACCOUNI'
<br /> —;:i.R *' Na Ill' 17111,141) IM 11U, �J,AGENCY IS RESPONSIBLE FOR WE COMPLEYTON OF111P,
<br /> -AL AENC"Y' USE, ONLY' IN'W PA)X AND FOR FORWARDING ONE FORM WAND
<br /> ANI,(,)('tATl.']') DORM 'B'(s) TO '1'1, ---OW UNGADDRES&
<br /> 1iTA11T 011 iVORNTA
<br /> SrNll` WATER RPNOURCIS COWROL BOARD
<br /> C10 1S.W1-1-'F-P-&
<br /> 6)VIA PROIGE&SING C'EMIM
<br /> P.0, BOX 51,11
<br /> PARAMOUNIF, (A 90723
<br />
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