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IRRIP11119W
<br />COMPLLAIN6 F()RM 'A'
<br />I. One FORM 'A" shall be completed for all N1, -W PE I'S, PL7Rmrr C-11ANGI-N or any FAC'Uny/snu,
<br />INFO `PION CHANGE&
<br />I SUBMIT` ONLY ONE (1) K)RM "A' for a Facility/Site, regardless or the number of tanks located at the site.
<br />3. This form should be completed by either the PERMIT APP11CAN17 or the LOCAL AGENCY UNDERGROUND
<br />TANK INSPPCI'OR.
<br />a. Please ly� or print clearly all requested information.
<br />S. Use a hard point writing instrument, you are making 3 copies.
<br />JW- 'MARK. ONLY ONE rrEm"
<br />ark an (X) in the box next to the iter: ?at best describes the reason the form,is being completed,
<br />4.
<br />lA(-0,ltY/SF MT INFORMKIION & A10!)K1,&, (MUST BE-COMPMqM)
<br />1. Record name and address (physical location) of the underground tank(s).
<br />Nam Address MUST have a physical �-cation including city, state, and zip code.
<br />P.O. BOX NUMBF;V-, NO7f AC,0T115,U3fF-
<br />Include nearest eros- t and name c,,0ie �,p,;rator.
<br />2. Phone number must leave ar, Tr 1, �!se same, write "SAME" in proper location,
<br />3. Check the appropriate.box f� 4S OW.XFI�.SHIP (ex. CORPORATION, IN[)IVIDUAI,', etc.)
<br />4. Check the appropriate bo)t
<br />S. If Facility/Site is Ion, I ed wit ss=a or other Indian trust lands, check the box marked "Yf-W'.
<br />6. Indicate the NUMW of'I
<br />7. Record the E.P.A. h d or tv;w in the �acc provided.
<br />0 DROPETTF-1i OWNPIR IM Y '1 "01VIION & ADDRF-,11', ('OWILFIED)
<br />Con ,' 'ta all items in this section, unless all i 5 ,. same as I�FCTION I.; if the same, write 'SAMF As SrIV* across
<br />this Be sure to check PROPWIT TYPE box.
<br />W- L'%NY tj n 1 INK)RALAUION & ADDRESS (MU,1' 1:1
<br />:A
<br />;ter;,� in this section, unk--, -ry erre as SECI'ION 1; If ithe same, write *W,411A
<br />sure to check TANY -Sit-V YI,fl
<br />,�CCOUNI' NUMBER (MUST BE COMPLE'flEP)
<br />IV. BOARD 014 LOUALIZN1101i L;,�A
<br />Enter your Board of Foulilization (1301'i T7S-T'sw,,,lg,- fee account number which is required before your pc7rmft application
<br />can be processed. Rr,,,;,,,tration with t' evil' -n,,ure that you will receive a quarterly storage fee return in reporting7the
<br />%0.006 (6 mills) pe-. dne on of gallons placed in your UST& The BOE will code persons exempt frons
<br />paying the storm : cc
<br />will not if you do not have an account number.witb the BOE or if you have any
<br />questions regarding the fee ur ,,ti ase call tht, I 01`1 at'916-323-9555 or write to the BOE at thefolfi)�ing address:
<br />Board of Equalization, Emiron,., ift, P.O. -42879, Sacramento, CA 94279-0001.
<br />V Fllli'ROLEUM UST FINANC7AL RF
<br />XY (s < ( "A' BE COMPLE7MD)
<br />Identify tl.0 method(s) used by the owner and/or o- in meeting the Federal and State financial responsibility
<br />requirer-,,,vs. USTs owned by any Federal or Stagy vncy are exempt from this requirement.
<br />VI- 11,1KYAL N011FKA11ON AND 13!11.i--'Y,t ADI V,i-1"'
<br />Cbecl,- ONT, BOX for the addre,---. at -ilt be used for B(MI UiGAL AND INIIJNG NoTIFICNIIoNs.
<br />The county a s, jurisdicti(,- are pxedctern-o:„,:d and can be obtained by calling the State Board (916)719-2421. The
<br />f number: numbtmay be a<, �,-nz:u me joca� o1c,, this number must be numerical and cannot contain any
<br />lIabctical. If the local lc-ncy prefers tf«: P assign the facility number, please leave it blank.
<br />IS ITTE, fAESJ,1 aNsl THAT INSPUMNIIIE FACILITY TO VFRIVY '1111i”
<br />VV
<br />OF Wi, ,s„AWII
<br />PUION CANN(Yr BE PROCESS'F
<br />D IF IIIE 14W ACC )kjVt'
<br />Nkfl' 'FF , TNCY IS RESPONSIBIX FOR '111E COMPLETION 01
<br />NCY 1 FORWARDING ONE FORMA" AND
<br />A -jSl, ?WPI' IC AND FOR F
<br />AIJDRESS.
<br />,iA�--OHMA
<br />'1°t I` MIROL BOARD
<br />'s C
<br />PARAMGGG';V, CA %rl
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