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<br /> 1. One VOIZAI "A", shall be completed for 7Jl NEW PE;RWI;S, PE4'RMrI`t IAN(;E_S or rano FAC'II,I`CY/S111
<br /> INI'OII.MA`11ON CEIANGES.
<br /> 2 SLTBmirr om.Y' ONE (1) FORM "A for r Facifity/Site of the number of tanks located at Clic siic
<br /> 3. 'nis form slioutd be completed by eitb,-,r the PERMIT APPIICAmr or the LOCAL AGENCY 1.7tNDl W"IZOUND
<br /> 'LANK INSI FC.I`)R_
<br /> 4. Please type or print clearly all requested informt,ion.
<br /> 5. Use a hard point writing instrument, y.)u are making 3 copies.
<br /> OF POR "MARK ONLY ONI I'P0W
<br /> Mark an (X) in the box next: to the item that best describes the reason the form is being completed.
<br /> I. FAC ,,.,.Y/srrE:Y INFORMN11ON &. ADDRESS vSS+II SSE' BE C.°OMPL,;EVD) '
<br /> 1. Record name and addre:» (physical to ttfM i of the under r� enc? tank(s).
<br /> NOTE: Address i9US"I' have a valid !hysial location incltit i xgity, state, and zip code.
<br /> P.O. BOX NUMBERS ARE VO WC17YABI_E?
<br /> Include nearest dross street ai= ^ of the operator.
<br /> 2. Phone number must.have an area coif ii the night number is the saltie; write "SAME" in proper location.
<br /> 3, Check:the,apprgp:riate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA110N, 1N171V1I)UA1,. etc.)
<br /> Check the appropriate box for"I`YPE OF BUSINESS.
<br /> If Facility/Site is located Mtbin ars Indian reservation or other .Indian trust lands,check the box marked "YES".
<br /> dicate the NUMBER ofTANKS at this STrE.
<br /> Record the E.P.A. ID ## or write "NONE" in the space provided.
<br /> i'Y OWMIR YWORMA711ON &AT)DRFS.S (WS-F BE WMPLEZ7193)
<br /> t,oinplete all items in this section, unless all item are the same as ST C;T1C).V 2; if the same, write 'SAME AS 5tI1S° arec3ss
<br /> falls a=e io check PROPERTY OWNERSHIP'TYPE? box.
<br /> t O Ca1°R 1N'i�yi���<VITON & ADDRI3SS (M$.7!s`I'ETE.C OMPLE`nI D)
<br /> Complete all items in this section, unless all iters are the same as SE(710N 1; If the same, write ".SAME AS SI'11;" across;
<br /> this section. Be sure to check 'rANK O -UP TYPE?box.
<br /> I'8='. BOARD OF EQU '-.ATTON U~°317 )RAGE FEE AC:. UNI NUMBER S17 BE CXWPIX-314 ?)
<br /> Enter your Board of Ii qualizaiion (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 storahe fee return in'reporting the
<br /> a $0.006 (6 trills) per gallon fee due on the number of gallons plarcd in your UST's. The BOF.., 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 /> :,.aestions regarding the fee or exemptions, please call tht� B01" at 916-323-9555 or write to the BOF at the following address:
<br /> hoard-of Equalization, Environmental Fees Unit, P.O. 'Box 942879, Sacramento, CA 94279-OE107..
<br /> V, €'.iTl�_OI,EU'M LIST"FINAWIAL RE'SPONSIBHXff(MUSE'BE COMPLE-fED)
<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 Fe€icral or State agency are exempt from this requirement.
<br /> V1, r . .,,'_Y11F[CWrI0N AND B1, .IN G ADDRESS
<br /> Check ONE BOX for the addiress that will be used for B(YI'H LIXIAL AND BIUING N011 ICA1"IONS.
<br /> ; Yr MUS r&GN D DATE 11W,FORM AS INDICAI'ED.
<br /> r'AION FOR THE LO AL AGEN
<br /> The county and jurisdiction numbers are predetermined and can be obtained by catling the State Board (916)739-2427. The
<br /> facility number mai, be assigned by the local agency; however, this number must be numerical and cannot contain any
<br /> alphabetical. If local agency prefers the State board to assign the facility nuin Per, please leave it blank.
<br /> ri, IS'IIn. ",t''.ggs a :}If E'a OF"n W,LOCAL AGE?NCa :"-!A-.' d viz t'azCT�'i`1g18 IF}(II TL°a ICs vl.v, v "`
<br /> AC t ,f � T[ORT. ITS AI'I'I IC �Ta edl3`I I3[{ l'1Zi�f 1�xS;I? i` `�i1 sI. 1ti'gf F
<br /> FU IMP ?, „ �,I, (CIL `-Po RU->,t d i�SI131.1; i t.)1 R'III. : ?�91 #.t v$11'.".
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<br /> }, C ' " EN1';a1 i`l"N COX A;�i 3`Chit 11)I� AILI?IN�a C�PdI:'-I'=xlO iy
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<br /> S% OF CTJ `ki',,4,�
<br /> S C)PTI"Ifi A,BOARD
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<br /> 90723
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