|
INSERUVIIONi FOR COMPL11,71ING FORM W
<br /> GIWERAL INS71'RUC711ONS'
<br /> 1- One FORM "A" shall lie comnleted for all NEW PERMIJS, PEIRWTCHANGESor FACILITY/SrIV
<br /> INFORMATION CHANGE-S.
<br /> 1 SUDWFONLY ONE (1) FORM *A* for a Facility/Site, regardless of the number of uinks located m the si';�
<br /> 3. This form:should be completed by either the PERMIT AITTICANFor the LOCAL A(;I,',N(,Y UNDFRGROIt Nl)
<br /> TANK 1NSPFC`POR_
<br /> 4, Please type or print clearly all requested information.
<br /> 5, Use a bird point writing instrument, you are making 3 copies_
<br /> 'MP 017 FORM_ 'MARK ONLY ONE rITNI"
<br /> Mark an (X) in the box next to the item that best describes the reason the form is beim, com'plelcil.
<br /> L i?Acii.,nN/,%r.rE iNFoRmxrtoN & AJJDRU§* (MIDST"BE COMP117,1ED)
<br /> L , 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 cock:
<br /> P.O. BOX NUMBERS ARE Nur ACC IWAB111
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same, write "SAME"
<br /> " in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, ere:.)
<br /> 4. Check the appropriate box for TYPE OF BUSINF',SS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked
<br /> 6. Indicate the NUMBER of"I'ANKS at this sm.s.
<br /> j7. ff- Jecoid the E.P.A. 11) # or write "NONE" in the space provided.
<br /> 11. PROPFRTY OWNER 1NF6RiAN1ION& ADbRtw's (mlfsr BE c0mpuirrlil))
<br /> Complete all items in this section. unless all items are the--ame,as'SEC11QN I; if the same, write "SAME.AS S111""
<br /> this section. Be sure to check PROPL.KFY OWNS RSI1TP TYPE box,
<br /> 111. TANK OWNER INFORMA'11ON &ADDRESS (MUST'BE COPLL-171))
<br /> Completc, all items in this section, unless all items are The same, as SFCTION 1; If the sante, write 'SAME. AS SfJI*
<br /> this section. Be sure to check TANK OWNERSITIPTYPE lox.
<br /> IV. BOARD OF EQUALIZA17ION USiI'STORAGE FEE.ACCOUNI'NUMBER (MUS-r BE cOMP11mm)
<br /> 13Mfer your Board of Equalization (BOE) 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 /> S9.006 (6 mills) per gallon fee due on the number of gallons placed in your USrs. The 1301_,� 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 1301? or if you have any
<br /> questions regarding the fet or exemptions; please_call the BOE at 916-323-9555 of, write to the BOE at the following address:"
<br /> Board of Equalization, Farviromnental Fees Unit, P.O. Box 942879, Sacramento, CA, 9,1279-0001,
<br /> V. Pl-.,.-I'ROIEUM U91'FINAN(.3AL RESPONSIBIL171Y (MUer BF COMPLEI-E-1))
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. UST's owned by any Federal or State agency are exempt from this requirement.
<br /> VL LIXiAL N(Y11FICATION AND 13111ING ADDRMS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND 13111I.ING NO`17IFI(Wn0NS.
<br /> AITTICANY mus'r SIGN AND DA'17E'1111, FORM AS INDICW11:11).
<br /> iNsTRu(Tj1ON FOR 111E LOCAL AGENCIES
<br /> 'The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The
<br /> facility number may be assigned by the local agency; however, this namber 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 /> rr IS'nut RuspomsiBuiry oll-illE LOCAL AGENCY THA.1'1NSP1X,IS,rtjE mciury ro 'VE RiFY 'nip.
<br /> ACCURACY OFT 11," INFORMA71'10N. TIJIS APPLICA711ON CANN(Y1'BE PROCE&SED IIS 111E BOEI ACCOUNI,
<br /> NUMBER IS WYP FILLED IN. '171E,LOCAL AGEf4CY IS RE-SPONS1131,17, FOR THE COMPLUJION OF 7I I1E
<br /> *LOCAL AGENCY USE ONLY" INFO1 N170N BOX AM.) FOR FORWARDING ONE: FORM W AND
<br /> ASSOCIATED 17ORM -il"(s) TO '11IF, FOLLOWING ADDRI%-.%.
<br /> SF/VITT OF CALIFORNIA
<br /> IOWIE W)VIER RU-SOURCE; BOARD
<br /> C/O
<br /> DATA PROCESSING CI WER
<br /> `P.6 i1OX 527
<br /> PARAMOUNr, CA 90723
<br />
|