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INS.rRIJ(711ONS FOR COMPLIA'ING F()RM A7
<br /> GENERAL INSTRUC)IONS:
<br /> L One FORM "A' shall be completed for all NEW PFRMFIN, PERmrr CHANGE-S or any FACI1.rIY/SITI
<br /> INFORMX11ON CIIANC ES.
<br /> 1 SIUMMI'FONLY ONE (1) FORM W for a Facility/Site, regardless of the number of tanks located at the si1c.
<br /> 3, '11is form should he completed by either the PERMIT APHICANFor the LOCAL AGENCY UNDURGIZOUND
<br /> TA
<br /> NK INSPIX'I'OR,
<br /> 1. Plcasc IvVe or print clearly, all requested information.
<br /> 5Use a hard point writing instrument, you are making 3 copies.
<br /> TOP OF FORA& "MARK ONLY ONE ITI'MW
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed,
<br /> 1. FACILWY/Sfll °17ON & ADt)Rt-zSS (MUSt 131f COMPLUFED)
<br /> Record name and adAi4l (physical location) of the underground tank(s).
<br /> Address MUST have a valid physical location including city, state, and zip code.
<br /> PO. BOX NUMBE RS ARE NCn'AM.EFFAB111,
<br /> Include nearest cross street and name of the operator,
<br /> the same, write "S.ANIF" in proper locaiic)n,
<br /> Phone number must have an area code. If the night number is
<br /> 1 Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. COM'OIZATION, INLAVIDUAL cic.)
<br /> 4. Check the appropriate bbx for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YN'S".
<br /> 6. Indicate the NUMBER of TANKS at this SITF.
<br /> 7, Record the F.P.A. ID # or write "NONE" in the space provided.
<br /> 11. PROPH'R`J'Y OWNER INFORMA'FION &ADDRESS (mu5r BE COMPTH171-41))
<br /> Complete all items in this section, Vmless, all items are the same as SECI'ION 1; if the same, write "SA CI AS SHT'! across
<br /> this scction. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> 11L TANK OWNER INJk)RMA71-1ON &ADDRESS (MUSI' BE COMPL1.-TFD)
<br /> Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS Srl'f-,.' across
<br /> this section. Be sure to check'YANK OWNEW411P TYPE box.
<br /> IV. BOARD OF 17A)UAT17AIlON USI'SFO GE ITE ACC( UNr NUMBER(MUST BE CAWPL[3110)
<br /> Enter your Board of Equalization (BOE) U917 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 /> SOA06 ((i trills) per gallon fee due on the number of gallons placed in your USPS. The BOE will code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BOE or if you have any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address:
<br /> Board ofEclualization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001.
<br /> V. PE'FROLUUM FI r FINANCIAL RESPONSIBUJI`e (mu5r BL compimim)
<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 IJ?.GAI, NO711FICATION AND BILIC$ADDRESS
<br /> Check ONE BOX for the address that will be used for 130111 I,EGAL AND 11111ING NO11FICA11ONS.
<br /> Appi..rcNw muss SON AND 11NITI 1TIE,FORM AS INDI(WITI).
<br /> INSIRU(NION FOR`FI E LO(:A1,AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242E The
<br /> facility number may be assigned by the local agency, however, this number must be numerical and cannot contain any
<br /> atphaiietical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> LI'IS'1711F, "1'O 'IBB OF 171E LOCAL AGENCY 'TUNr INSPECif'S'I)IE FACILrYY 170 VERIFY'17W
<br /> ACC'URAC'Y OF-1171TE INFORMATION. '171IS APPI.JC'YV[10N CANN(Yr BE PROC&,SSUD IF 11fF WWI ACCOU"Irl'
<br /> NUTM-BER IS NOl' JqLTYD IN. Illt,"LOCAJ,AGW(7Y IS RF-SPONSTBIJ, FOR'111E COMPLE-110IN11, 01"
<br /> 'LOCAL ACArNCY USE ONLY' INFORMN-DON DO X AND FOR FORWARDING ONE FORM 'A" AND
<br /> ASSO(-'IXrFD FORM W(s)TO THE 17011,OWING ADDRU',S',S.
<br /> STAIV OF CAIR,'ORNIA
<br /> 517A'ni,WATER RESOURCES CONYROT,BOARD
<br /> C/O S.W11HP.&
<br /> i
<br /> DNIA PROCESSING CT.NPER
<br /> P.O. BOX 527
<br /> PARAMOUNF, CA 90723
<br />
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