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A
<br />INSMUMONS MR COMPIA FORMW
<br />GENERAL 1NsrRucnONS-
<br />1, One FORM "A" shall be completed for ill NEW PER10TIN, Pl.sRMD' �'HANGFN or aev FAC ILYIN/Sul v.
<br />INFORNIMION CHANGE-&
<br />L. SUBMI`I'ONLY ONE (1) FORM, Wfor a Facihly/siw, rcgardiess 0 �h, mnks localeddr th,"
<br />3. 'I'his form should be completed by either the PERM11' APHICANI'c, 'WAI, AGUNCY I,'JNDFRZ(iR0l
<br />TANK IN%Pa:I'OR.
<br />4� Please type or print clearly x311 requested information.
<br />5. Use a hard point writing instrument, you are making 3 copies.
<br />1XV OF FOME "MARK ONLY ONI, 111W
<br />Nlark an (X) in the box next to the item that best describe-, rhe rcl' on the form is being compleled.
<br />L FACILYFY/SfrE & ADDRESS (MUSF BE COMP11.1-11TD) t
<br />1. , Record ripme and address (physical location) of the underground tank(s,).
<br />N011_`. Address MUS`r have a valid physical location including city, state. and zip code.
<br />P.O. BOX NUMBEWS ARII N(YI'AMWABLF'
<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" in pic.gper location.,
<br />1 Check the appropriate box for WPE OF: BUSINESS OWNERSHIP (ex. CORPORMION, INDIVIDIJALetc.)
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located within an Indian reservation or other Indian trust land-,, check the box marked 11YES",
<br />6. Indicate the NUMBER of 'TANKS at this srrE.
<br />7. Record the E.P.A. 11) # or write "NONE" in the space provided.
<br />IL PROM R. OWNER INFORMN110N & ADDRESS (MUS'l' BE COMPIA:1111))
<br />Complete all items in this section, unless all items are the same as SE(TY10\ 1; if the same, write 'SAME AS Sulas is
<br />-
<br />this section, Be sure to check PROPEIVI'Y OWNERSHIP 'ryt,ie. bc.s,
<br />111 TANK OWNER INFORMA11ON & ADDRESS (MUSI'BE COMPLE311))
<br />Complete all items in this section, unless all items are the same as sl'.'(,.l [ON 1; 11' the sante, write "SARI? AS S111' across
<br />this section. Be sure to check *FANK OWNR%SIITP'1'YPH box,
<br />IV. BOARD OF FJQUAIIzNnON US'I'SFORAGE F1,111 ACCOUNI'NUMBER (MUS -F BE COMPwmD)
<br />Enter your Board of Equalization (BOE) USI" 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 />$0M6 (Cr mills) per gallon fee due on the number of gallons placed in your US'I's. The 130E will code persons exempt from
<br />paying the storage fee so returns will net be sent. If you do not have, an account number with the BOF or if you hnve any
<br />questions regarding the fee or exemptions, please call the BOl` at 916-323-9555 or -write. to the BQT_,, at the followin, address:
<br />Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001,
<br />V. PT-MROLLIUM US717 FINANCIAL RFNP0NSJBunY (muS-.r. BE COMPt.14-Iii,D)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. US'I's owned by any Federal or State agency are exempt from this requirement.
<br />VL LWAL NO'11M"ATION AND BUJING ADDRESS
<br />Check ONE BOX for the address That will be used for BO111 LEGAL ANT) B111ING MY11140VIIONS.
<br />APPLICANT MUST SIGN AND DAIM 1111-i FORM AS INDICNI10.
<br />INSMUMION FOR '111E LOCAL AGENCIFS
<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, nuniber must be numerical and cannot contain any
<br />alphabetical. If the local agency prefer-., the State Board to assign 111C facditv numbert please leave it blank-,
<br />rr IS 'rjnRESPONSIBI111'Y OF '173.11 LOCAL AGENC`Y INSFEV-I'S '1111T FAC711XI-Y 'M 4f :; 111 ME
<br />ACCURACY OF INFORMA110N. 1111S APPLICA11ON (ANN(Yl'BF PROCESSE11) 1111111i B011; A(VOUM'
<br />NUMBER IS NOT MIJED IN. '1711., tOCAL A(;1-2N(,Y IS RESPONSMIJFOR TIM COMPLIMON OFITIE,
<br />"TAXAL AGENCY USE ONLY' INFORMMION BOX AND FOR FORWARDING ONE FORM "A" AND
<br />A,SkSOCIAWD DORM 'B'(s) -1-0 FOLIA)WING ADDRF'_'!S:.
<br />,517NIE OF CALMMISTIA
<br />SJWPII WNII:',R RFSOURCUS (X.)N'1'R0L BOARD
<br />C/o "s W _fltu"_&
<br />DATA PROCE&SING CEM17ER
<br />P.O. 13OX 527
<br />PARAMOUNT', CA 90723
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