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GENERAL INS-1.71ATI10"N:
<br />1, One I'ORM 'Wt ri;ha:l br ec i 1-i all MIN' PERMUS, PERNAM' CIIANGFS or any FACILITY/SITU
<br />of larks locatcd ,it he,
<br />ONLY ONLI'l (1) O;RM of dic riun
<br />shou,d '1P, compk.wd 1); tither 'me ITR2\41-1- APPLICANI' or the LOCAL AGENCY UNDER6ROUND
<br />cjc�,I% "'fli rcu�-,s,td in:ornl�,Imn,
<br />riting v)u are niaking 3 copies.
<br />TOP OF I XMKH,� K 01MICY ONE' CYE -W
<br />Mark <in the box nex" to, itera U at V-4 Jcwl-ibs the th(form il being completed.
<br />1. JFj%.('1jjTYjSFJ- P. INFO RMAIRM-11- 4,- 'ITID)
<br />i, R- -,-,,rd iamc and acidnH� 4r;,,'-s,'o� tanks}.
<br /><C 11 vldlrcs� Alus", hat .t V,,,�iiij iocation incjlldi V, state, and zip Code,
<br />PD. BOX Nf IMME'RUZ ARU NO- ACC1T7FABJX-
<br />Include cross �teci 1*�,J` cl omr?of
<br />Ilij,e mirXi"'r 7c-,�,, ha --v W', JXCJl -i• "I -,W` in plro��,,
<br />�1�gfit a'In her Sil
<br />3, Chexl, theqpj,-r(-,-prate ionic,. TYP�.' fill CORPORATION, IM
<br />i L 1,-EISS.
<br />appropri 'i 6,ox
<br />4. het.�k tile For 'I I
<br />f Facil4`1�itc is ,viffiw 1 lildian i Hier liadfian trust lands, check the box `YF
<br />6Indicate the -NC1A4M,R iii thi,
<br />7. 1tecci-d the ) -PA- 70 ve feat.
<br />H, PROPER37Y OWNER IN1* ;WW^110N -9, NDDR�-,Ns (NM UST PE COMPurldi))
<br />Cnrnplctc ?,fl ite"tn's in ihi., m„, 'r, a, i't: YlON 1: if the same, write ',SJiMF As SM'
<br />III, TANK OWNER 11 ili-,q
<br />c",ii. in S
<br />11 r I c t c t� n - a cAlloN i: If oic samcwrite "sAmj,., As sm.,,, acro,,
<br />i -X,
<br />IV, BOARD OF FOUALEZY,� NUMBER (MUSU BE comPTI.-rim)
<br />"i""ou'll itun+m wtich ii, ;%,quircd bcfote your permit appl ica I i on
<br />You vill receivc a �marterlv storage fee return in reportim, the
<br />(6, Pl- piaced in grtxar USTs, The BOF -will cccic persons excrnpi li-oill
<br />-)
<br />P�- Tilt, s�- j �6o not hn-ve d,C
<br />an �ounl nunitvr widl•the B(3 or if vou 11ave anv
<br />13" Wl at 916-323-`,5515 or write to the BOE at the f*olkiwini, nddre"S:
<br />k -i,- r ,128T,,. Sacrarnento, CA 94279-000L
<br />v, I E11- 3 1 z i L1. j jta.N -
<br />,t,ixtmg ibc Fedcrtil and State financial responsibility
<br />C., t. T i,�
<br />1 -"i-111 - exempt from this requirement,
<br />VI. LEGAL
<br />Cb�--Iy 0,0- W):,%,, 1ONS.
<br />!P�f Fif TJX,;AL AND BUJING N011F]CM
<br />APPLICANU" �,,PUSF SIGN ilOill) DAIETM71 -4,
<br />hN,<N'RU(MON FOR '111F LOCAL
<br />i
<br />co,liilv> and "nif i,:o-1 Ntained by calling the State Board (916)739-242'1. he
<br />t S, nust he numerical and ca ri CL Oto any
<br />hi iwin, _r nn( C
<br />aktill, if -V,k art= the facility number, please leave it blank.
<br />IT IS THE RUMNUMSPH0,1H,ki 111% 711V (-P, ('Y TFLAT INSPENTI'S 'IIIF? FACILMY TO VEM11PY TIM
<br />£1I' `1"11x`; Vie("RMA d 11 Ai111,'( 1j'JON CANN(YJ' BE PROCP�..SIU) TF111E FX)E ACC OUNt'
<br />NUMBFIR IS NOTjill', V"WNCY IS RESPONSIBLE FOR 111E COMPLETION OFTHE,
<br />" LOCAL AGUINCY US11-" ()MA"Y" n�WCY''CT —170N WX AND FOR FORWARDING ONE? FORM 'A." AND
<br />A,W)CINITID FORUM "1 Qs"' TO i'llE FOIJA)AIIN6 ADDRF-S&
<br />qIWIT, OF CAUFORMA
<br />WAJ ER RPNOURCES MWROL WARD
<br />C/o
<br />1`l,;%T,A flkjCENSING Cf,'Nif,"R
<br />P,C), "BOX 127
<br />PARAMIOUMI-, CA, �XY723
<br />
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