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-'-IfILEFING, FORMI W
<br /> GE, SAI,
<br /> L onc, F('W' A" 'ShaH be Comp feted to. ill NEW PERMUN, PER'llylITCHANGIN orary FACIVITY/SITIF
<br /> ."TIANGES.
<br /> 1 NU (1) FORM 'A' for a regardless ofthe number of lanks iocatcd at i'M'
<br /> 3- 'this form should be completed by either tic 111;'RMIT A111111CAM'or the: LOCAL AGLINCY LNI)EWIR(W\V�
<br /> TANK INSPEVVOR.
<br /> 4, Please tiT`c or print cleafly all requested information.
<br /> 5. Use a hard point wi,itin- instrument, you are making 3 topics,
<br /> 'MARK ONLY ONi_,-1 rrum-
<br /> X) in the boy next-to tht,, itcm
<br /> Clark 3;) be'st tfi.scribes the reariah'the r0l�ti`iS.bcing complc'tc(i-.
<br /> SV�43�,, COMPLE-170))
<br /> 111TYPS1"'C" mu ti
<br /> L. Rc,,rd name;and location) of the underground tank(s),
<br /> �Vldmss MUST hate, a vdid physical location Including city, state, and zip code.
<br /> P.O. BOX NUMBEIVS ARE Na r AcawrAnim-
<br /> Include nearest cross street and name cif the operator.
<br /> 2. Phone number must have an area code. If the night number is the same. write "SMYTE in proper
<br /> 1 Check the appropriate(bvx for'INPE. OF BUSINESS 0WNL1RSfJIP (ex. CORPORMION, INI)JVll)t'AJ_ ete)
<br /> 4. Check the appropriate box for TYPE OF BUSINITF�S&
<br /> S. If Facility/Site is located within in Indian reservation or other Indian trust lands, check the box marked
<br /> 6. Indicate the NUMBER of TANKS at this srm.
<br /> -7Record the 1",P,A or Fif) "No �, " in the space provided.
<br /> :
<br /> O"Ll-" i>4s 0L ADDRU-SS ('MUST BF*,COMPIM11)) A,
<br /> Complete all items in this section, unless all items ar,; the same as SIX-MON I; if the same, writc, *SAME
<br /> AS
<br /> this section. Be sure to check PRC PERIY OWNUIRSHIP TYPE box.
<br /> IA"'JK "WNCR lV '°MA �N &ADDRU&S (MU91' BE cofv[Pljin: l))
<br /> Complete all it to ia Ih4s'section, t;,qlcss A ilcr!ts'aio the same as SE(.'TI4N0l;"'1the"same, write '$AMD AS S411;
<br /> this section. Be sure to check TANK OV ",R IP'IYPE box.
<br /> IV. BOARD OF EOUALMNILION USI' I I'U"E"ACCOUNr NUMBER(Mt.js-r Bt,.'co4p'llnl.b)
<br /> Enter your Board of Equali4pilorr UST storage fee account number which is required bcfor,, � �jlth"ITI'W f'
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fcc return in ri.polw
<br /> $0.006 ((t mills) per gallon fee due on the number of gallons placed in your U91's. The BOE will code person-',
<br /> paying the storage fee so retu.ms will not be sent, If you do not have an account number with the BOF or
<br /> questions regarding the fee or exemptions, please call the BOE at fhe Rflo'wi.""
<br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942979, Sacramento. CA 94279-OWL
<br /> FINANCIAL RENPONSIB
<br /> V. I'MMOLEUM US un Y (mbth Bu, compurni))
<br /> Identify the method(s) users by the 6`1&',ner and/or bivrator in meeting the Federal and State Financial respons0fily.
<br /> requirements. UST's owned by any Federal or State alye-6ty are exempt from this requirement.
<br /> VL LI:TiAL NUMICAFION AND BlILLNG ADDRE&S
<br /> Check ONE BOX for the address that wilt lie used for BO111 1,17GAL AND BILLING N0111WIN17IONIS.
<br /> APPI J(ANF MUST SIGN AN J, a ixiv MRM AS INDICN1111),
<br /> INS-IRUCTION FOR THE LOCAL AGIMMS
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)719-2421, The
<br /> facility number may be assigned by the local agency: however; this number must be numerical and cannot contain any
<br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br /> Iff W111F R13SPOM1131111-Y V&N("V Ts=NINSPW: .J.S '11IF.FACILITY TO VEIRl" '111F
<br /> ACCURACY 0.1"ITIF INFORMAIV)N' THIS APPI R'A'i CANNO'Y BF 111,10CESSf.4,I) 117'1111;1 [101 ACCOUNI,
<br /> NUMBER IS TILLED IN. 11W i'4 'd 1S FOR 31113. 0C)MI'l ol:'111v
<br /> "LOCAL Mi VNC ONLY* INFO RP-A"', N 0
<br /> RJONG ONIi art'1.M 'A", ?N"4)
<br /> ASSOCIA1111 YOPM '111(s) TO i
<br /> G (TWIT'W
<br /> VARAMOl 1, CA 90723
<br />
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