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�f iZ77
<br /> INS FRUC11ONS IK)R COMPLI AI&RM, 'A'
<br /> GFNERAL INS1'RTJCI1ON&-
<br /> 1. One FORM"A" shall be completed for all NEW PERMITS,PERPAMCIIANGE�s or any FAQLI`I'y/STj'F
<br /> INFORMA'17ION CIIANGES,
<br /> 2. SLIBmrr ONLY ONE(I)IX)RM'A"for a Facility/Sitc,regardless of the number of tanks located at the
<br /> 3. This form should be completed by either the PERMII'AF'PI1CANr or the LOCAL AGENCY UND;7.RGR0lJ'.N';—YANK
<br /> INSPWFOR.
<br /> Please type or print clearly all requested information.
<br /> Use a hard point writing instrument,you are making 3 copies.
<br /> 'L'OP OF FORM:'MARK ONLY ONE 1`17W*
<br /> 1, Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FAC ILr1-Y/SrrE INFORMA71ON&ADDRE-Si(MUST`BE COMP11-110))
<br /> L Record name and address (physical location}`of the underground tank(s).
<br /> NO'FE: Address NII ,SI'have a valid physical local ion including city,state,and zip code.
<br /> P.,O,BOX NUMBER ARE NOrr ACCEFrABI1-?
<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 proper!�,m:on.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex. CORPORATION, INDI'VIDIL"AL,C!C.)
<br /> 4. Check the appropriate box for'FYPE OF BUSINESS,
<br /> 5. If Facility/Site is located.on land within an Indian reservation or other indian trust lands,check the box marked "YPS'",
<br /> 6. Indicate the NUMBER of'rANKS at this SITE.
<br /> 7. Record the E.P.A. 11) # or write'.N0NI--,' in the space provided.
<br /> 11. PROPFR'I'Y OWNER INFORMA-11ON&ADDRF:SS(MUST Bit COMP1101m)
<br /> 1. Complete all items in this section, unless all items are the same as SECFI0N J.; if the same,lwritve ',&AM17 AS S1`11,"across,
<br /> this section. Be sure to check 1`R011FR'FY OWNERSHIPTYPE box.
<br /> Ifl.'FANK OWNER INFORM)VnON&ADDRF-XI;(MUST'BF'
<br /> 1. Complete all items in this:sction, unless all items are the same as SEC-HON I; If the same,write *SAMI!&S Sfni!
<br /> across this section. Be sure to check'TANK OW3NERSY11Y1'1'YPH box,
<br /> IV BOARD OF 1X)UALI?.KJ1ON LISP STORAGE 11111?ACX7OUNJ.'NUMBER(MUsj'BI1 COMI'tri1j))
<br /> Enter your Board of Ujualizai icm (BOF.) US'I'storage fee account number which is required hufore your permit application can
<br /> be processed. Registration with the BOF,will ensure that you will receive a quarterly storage fee-return ih the`93,(W)
<br /> (6 mills)per gallon fee due on the number of gallons placed in your U91s. The BOE vill code persons cxcrnp.t from paring the
<br /> storage fee so returns will -tot.be sent. If ynu, (11,11,mkt have no account number with the B0111'or if Vou biv,- any
<br /> regarding the fee or exemptions, please(afl the BOY,.at 916,7339-2592 of write to the 130E at the following address; M.nird of
<br /> Equalization, Environmental Fecs Unit,P.0, Box 942379,Sacramento, CA 94279-(W.1.
<br /> V- I1X.;AI.NO111.110VI.ION ANT)11111ING ADDRIiss
<br /> 1. Check ONE 13OX for the address that will be used for I LEGAL ANT)B111,ING N(Y171FICATIONS.
<br /> Av,PLi(:ANr->"; SI` ANY)jwwnlijii FORM AS INDICAIED.
<br /> INS17RIN-11"'.,S" 1-1E LO(:AI,AGIN(I-ES
<br /> 'Fhe county and jurisdiction nv-Thc,-s are predetermined and can be obtained by calling the State Board(916)739-2,121, The
<br /> facility number may b, assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency pre',,,ns the State hoard to assign the facility number,please leave it blank.
<br /> rl,1"1',1UH, W1`-S1P01NSI[3II1rY 017111P LOCAL A(;]!NCY'11LIVI'INSPWt,S 31 ILI FACILITY`1"C)VERIFY11114
<br /> ,k(`� i"R (7y 11111F INFORMATION. THIS AP5111CS110N CANNOrl'BE PR(WF-SSE IF 111E B014,ACC()UNF
<br /> NT,'NW,4'-R,TS N0'F1`If1F1 IN. '11IF 1.00M,AGINCY IS RFSPONSIBIIFOWITIF CONIPWI.10N OF 11W'LOCAL
<br /> AGVNK,71�1 I ONLY' PDX AND lk)R FORWARDING ONE FORM'A'AND ASSOCl/V.119)FORM
<br /> k'S) 1`011,—V WGH AT)[
<br /> 51WIE OF CAI,YFC)�
<br /> S- ,`AM WYVDR RE.S01JR(1iS CONIROL BOARD
<br /> cyo sw.lui-P.S.
<br /> DA'I'A PRO (MSSING C 2W113R,
<br /> P.O.BOX 527
<br /> PARAMOIJNT,CA 90723
<br />
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