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<br /> INSFRUCI'IONS FOR COMPLFIING FORM 'A"
<br /> GENIt.RA,I. I
<br /> be completed for all NtiW PERMITS, PERMIT'CIIANGL S or any 17AC'ILI'i'Y/Sl'f7i
<br /> IN1,AZM,VJ JON ('MANGES.
<br /> 2. SUBMI71'ONLY ONE (1) FORM "A" for a Facility/Site, r,^gardless of the number of tanks located at the silt.
<br /> 3. This form sl ccri;3 ire completed by either the PERMIT APPIICANF or the LOCAL.AGENCY UNDI RGROIJND
<br /> TANK INSPL,,€;`£'OR w
<br /> print clearly all requested information.
<br /> a hard point writing instrument, you are making 3 copies,
<br /> -4-3: "M`IP°K ONLY ONE 1711 I"
<br /> Mark an (X) in the box next to the item that best describes the reason the form is being completed,
<br /> I. RACII1`IT/SITH INFORMATION&ADPRE,SS (MUSTBE COMPI.EWID)
<br /> 1. Record name and address (physical location) of the undergrowtd tank(s).
<br /> NOTE: Address MUSi` have a valid physical location including city, state, and zip code.
<br /> P.O. Box NUMBERS ARI?NOT ACCEPTABLE.
<br /> Include nearest cross street ancr name of the operator.
<br /> 1 Phone number must have an area code. If the night number is the same, write "SAME" in proper location.
<br /> 3. Check the appropriate box for TYPE PE OF BUSINESS OWNERSIHIP (ex. CORPORA711OiN, INDIVIDUAL. etc.)
<br /> 4. Check the appropriate box for 'I'l P1'. OF BUSINESS.
<br /> 5. If Facility/Site is located wifltin an Indian reservation or other Indian trust lands, check the box marked "YES".
<br /> 6. Indicate the NUMBER of. "T.AA.KS at this SITE.
<br /> 7. Record the E.P.A. ID # or write "NONE" in the space provided. r
<br /> I,L PROPERTY.OWNER INt C)RMAnON&ADDRESS,(MUST BE COMPI.EI'ED)
<br /> Complete all items in this section, unless all items are the same as SECI'ION 1; if the same, write '.SAME AS SI T7i" acro ss
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE.., box.
<br /> M. 'TANK OWNER INFOW&ATIO T & ADDRESS (MUST BE C OMPLE'[M)
<br /> Complete all 'items in this section, unless all items are the same as SECTION 1: If the same, write "SAME AS SPIT'" across
<br /> this section. Be sure to check '.TANK O ?R'SIIIP TYPE box
<br /> IV. .BOARD OI?EOUAI z-AnoN us1r SCO Cil?14m,ACCOUNT NUMBER(MUST BE COMPLE'IIa))
<br /> Enter 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 /> $0,006 (6 mills) per gallon fee due on the number of gallons placed in your USrs. The BOE?,will code persons exempt fro.in
<br /> pay4ng the storage fee so returns will not be sent. If you do not have an account number with the,BOE"or if you'h ve wiv
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following acldre s:
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942579, Sacramento, CA 94279-01001..
<br /> V., PETROLEUM UST FINANCIAL.RIa'SPONSIBIL 17Y (MUST'BE C:OMPI.EM))
<br /> Identify the metbod(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> j requirements. UM owned by any Federal or State agency are exempt from this requirement.
<br /> I
<br /> VL I.EGAL NOTIFIC.ATLON AND BII.IING ADDRI,:SS
<br /> Check ONE BOX fcr the address that will be used for BOTH LEGAL.AND BILLING NOIIPIC TIONS.
<br /> APPLICANT MU`I'SION vJi JT 0,' FORM V� 1NDIC.AL7ED.
<br /> INSI'RUCITON FOR TIM" V,"C i
<br /> The county and jurisdiction num! -r> are rri Aeterntincc <wdf can be obtained by calling the State Board (916)739-2421. The
<br /> facility number may be. assign< ,.ie local agency: however, this number must be numerical and cannot contain any
<br /> alphabetical. If the local ale, ;..;ers the State Board to assign the facility number, please leave it blank.
<br /> n, IS rlr ; U 'LCIS =TiL, LOCAL.AGENCY THAT INSPECTS HIE FA(MM'Y TO VERIFY 1TIE
<br /> ACCUIfI+I" OI' 4'ON- THIS APPLICATION CANN(XC BE PROCESSED IF T'HE BOL?ACCOUNI,
<br /> i4"'=u IW! `3 N(Yl :'4'., ,s1 IN` I l9' I.t CAL
<br /> AG 'Y IS RESPONSIBLE It'()R TIII;COMP?ETION Oil 17IF
<br /> rA l tiI,NC`Y '_, ONLY" I:�: €JfsMA:"ION BOX AND FOR FORWARDING ONE FORM 'A'AND
<br /> 7"D FO V t }`J"%.D 'ilia: 14tl.i OwlN(i ADDRESS.
<br /> J'A<_ �N i i ft P+>`.M0 COttit1.'ROL BOARD
<br /> t I t 30"I:til t p CEN FER
<br /> 6":1IZ;. F, CA 90723
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