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INSTRIA.711ONS FOR COMPLE . 10MM W
<br /> GVNF,JfAI. IM;]RUCHONS;
<br /> .1. one YORM "'.V" shall he compIcied for afl NEW PIMMMS, PERN11T CHANGES 0' ;wFM'liTIV/'roHV
<br /> INFORNIM ION CHANGE&
<br /> 2. SUBmn, ONLY ONE (1) 17ORM W f'rr ,4 !iwilitv;Site! rcgarjlcss ,a
<br /> 1 Thi'13 form should be completed by LifhcT ih,, 1'ERN111' APPLICAN1 or the [,()(,At, A6EN(A'
<br /> TANK INSPECTOPL
<br /> 4, Picase ty,Pe or print clearly all requested information,
<br /> 5- Use a hard point writina instrtiment, you are making 3 copies.
<br /> 1`011 Of' FORM: "MARK ONLY ONE, TFU'
<br /> .Marl, an (A) in We box nowt*('o-dhe item that describes the reason the f0l"m i'l hcn__
<br /> 1, FACUITY/SfFE: INIFORMA-11ON & ADI)RMS,(M.U5r BE (X)MIIT1i1711))
<br /> 1. Racod name and address•(physical location) of the undergroelld tank(s),
<br /> NOTK Address ML,'ST a Valid physical location alcfeding cily, stale, and
<br /> 1p
<br /> 11.0. 13OX NUI4 13ERS ARE, NOT ACCEFrAMIL
<br /> Include nearest cralid name of the operator.
<br /> 1 Phone number must have an area code. If the night number is the same, write "SAW" in proper localion.
<br /> 3, Check the al,1.)ropriatc,box for TYPE Or, PUSINT-SS OWNE.1.61111, (ex, CORP(?RATION. INWVlM_'AL, oc )
<br /> 4. Check the appropriate ibox for'IYPE' OF BLTSINFSS,
<br /> S. If Facility'/Site is located within in Indian resenatior or other Indian trust lands. check the hoy
<br /> 6, Indicate the \UMBI-;R of TANKS at this SITE.
<br /> 7. Record the ETA. ID # or write "NONE" in the space provided.
<br /> 11. PROPER IT OWNER INFORMM.70N & ADDREWS (MUS-1, RE' COMI'liniu))
<br /> Complete all items in this section, unless all items an; the same As SECT17](YN' 1.1f write, 'SA\4fAS Sk 17Et'.
<br /> this section. Be sure to check PROPER'T'Y OWNFRSIIIP TYPE box.
<br /> III. TANK OWNER INFORMATION & ADDRE% (mvu BE COMM I?'
<br /> Complete all items in this section, unless all items are the saga»as '1AVI1()'4, l.;If 11ye',9ajmc i4ite *SAMV-AS,S171'P4
<br /> this section. Be sure to check TANK OWNEY—SHU-17YPE box.
<br /> IV. WARD OF WUA1.17N.IION U91'91'ORAGE ffirl ACCOUNT NUMBER musr BE ('oPI
<br /> tnt
<br /> er yb'ur Board of Equalization (1301;) usr stbrade fee account number which is required before your PCrniilt a
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return ill repos
<br /> $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The 130E will code Iyer" cats=
<br /> paying the storage fee so returns will not be sent. If You do not have an account number with the IfOl'
<br /> questions regarding the fee or exemptions, please call the BOF at 916-323-9555-co write,to the BOT'.
<br /> Board of Equalization, Environmental I-ees Unit, P.O. Box 942879, Sacramento. CA 94279-0001.
<br /> V. PEITROLEUM U,`;1'FIMFICIAL RiiispoNsumnT (MUST 1#. compurnm)
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial respon.siNli1v
<br /> requirements. L:517.,.; owned by any Federal or State agency arc�,exenipt from this requirement.
<br /> VL LMALN01MCNVION AND 13111.111ING ADDRESS
<br /> Check ONE BOX for the address that will be used for BO'111 MGAL AND 13111JING NO'171fIC1MIONIS.
<br /> APPI.i(ANr MUT SIGN AND DIVI'Ll UIE FORM AS INDI(W110,
<br /> INSIMUMON FOR 111E,LOCALACHINCIFS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)719-2421, The
<br /> facility number may be assigned by the local agency: however, this number must be numerical and cannot contain any
<br /> _=
<br /> If the local <i,ency prefers the State Board to assign the facility number, please leave it blank..
<br /> rl' RF_',iI1r,4t1lJLTFY OF THE LOCAL AGINCY ']'FIAT INSPI1C-14 TIM FAC11 I i A VMZIFY TlIF
<br /> ACCLIRACY 01' 0 1t? TNFORMIAMON. 11WS AT'llf V 4`AINN; i
<br /> YV fill 11' 11W, BOF AV(o:VI
<br /> NUMBER IS NOT IN. JTIE LOCAL AGE-NCY P, 'N'-dBIJ, l'ltR illF RYI�JITVHON� OF'1111"
<br /> *LOCAL AGENCY USti,ONLY* INFORMA11ON 13OX ANP 1�(A? VOWIVAR"I'llN(i FORM "A" wilt
<br /> A,SSO(3YVllD FORM W(s) 1`0 -11W FOLIAWING ARIM I
<br /> WA'11:3 OF CATIFORMA
<br /> SMIM WAIT R RESOURCES CON R01, 11()ARD
<br /> C/O S.WJLT 11 P
<br /> 'R
<br /> DNrA PROM&SING (TWIV.
<br /> P.O. BOX 527
<br /> PARAMOUNT, CA 90'723
<br />
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