|
GIMRAL y IMI;FI1.I1C" IONSa
<br />l., One f' JIM "A" shall be completed for all l: PRM IE � "I` E. 1 ANGE1; eS or arty t� C LILY/ M,
<br />1 SUBMrf ONLY ONE (1) MRM 'A' tsar a i acet;tty/Sita, regardless of the numtx r of tanks located m fhe,,snr€
<br />3, This forrn should be completed by other the M..,Rvirr APPLICAmr or the I )€1111, AGr,`T4C7t' UNI)Ii1Ptt4i„C)t<, Ii TAI
<br />4. Please type or print dearly all requested mfcirn ati€tn;
<br />S. Use a heard paint writing instrument, you. are, ntakan6,3 copies-
<br />Ibis OF FORM 'MARK ONLY ONE ram,
<br />1, Mark an (X) in ib box" atcxt to the rue. drat best describes the reassili he flea) is i entg cot.tfttr t€d. T ;
<br /><. er d tale and addre a; pht zs i'fo :aticin) of t@Bc. u�r Ica° round arrk(s
<br />C)i1.,. `x t dress MUS.Fhavc to valid physical i cation including arty, state, and rep ccele,
<br />_P.O. ��MTIER ARE ( r,AUITAB1 � ...o'..
<br />Include nearest crass street and nanre of the apt n= t€ts
<br />?, Phone number must have an area code. If the aright nurntic r is the earne, write in proper ]c,,c ttic sr."
<br />3, Check the appropriate box for TYPE OF S3t,ISINE.SS ty sNFRSHIP (", C:C;RI'(,'-,?RAE'ION, INDIVIDUAL, etc.)
<br />4. Check the appropriate 66' x for "T"YPE OF LJTSINE ,,S,
<br />5, if Facility/Site is located on land within art it than rect.vation or other indian trust hands, check they box rnarked 'YI€S".
<br />fie Indicate the NNUMBE3 R of"I'ANKS at this Sl"f" ,
<br />7. Record the ETA, ID # or write "NONE" in the .apace. provided,
<br />1, PROPEI<FY OWNER INFORIANTION As ADDRT xS ( LJ,1U- BE Y g` .
<br />1. Complete a!9 sCcaais in this section, unless air' ten,, are the ssztttx ,as SEa-C7l l()N 1; afi the dame, write 'SA f1 AS SL '1 " across
<br />this section. Be ware to check ]'RC?E'I,PXY OWNNE SIIff °I " it bo x.
<br />111. TANK C)' NEM INFORMNITON & ADDRESS (MI)Sr IIF MMP1,11'11sd))
<br />1. Complete all items in this section, 'unless all items are the same as `sEC `IC: N I; if the sazrne, rite "SAME AS S,1'111"
<br />across this section. Be sure to check , -
<br />,L - t1 i 1 aE11I" "t '13ltctx.
<br />IV BOARD OF rQUALIM11ON CTS`F IX) Glx I MI AC,(X)UfTr LJM11 f „ ,. T I1EC P1 Irlu ,
<br />�.
<br />Enter your#card of Eklualtration (130F') UFI' st€arage fee accousat n atnt € r which is z Flu vd before your permit application rase
<br />�p i3¢< rc c s . ,, elititrat:ion with $ick;. -T e will ertsaa'r���d.fa t yetis wilt receive a quarterly storage fee return in re.p€trtiit ;t "t)CAf€,'.,,
<br />(t, aiiils),Jtcr iftli n fee due on the number, of gallons placed in your US s. the BOE will code personas exempt from paying the
<br />storage tee ser returns will not be sent. If you do not have an account number with the BOE or if you have any questions
<br />regarding the fee or exemptions, please calf the 110[i at 916-739-2582, or write to the BOE at the following address: Board of
<br />TRIualiration, . ,nv-ironmerttal hers I1nd" PXX Box 942879, Sacramento, CA 94279-"l.
<br />1. Check N f I3O for the address that ill Pte used for 11I 1 Ill ..a . � � 1'' I i L ) I Ct I C)1V �
<br />MUSrSIGN AND I /Mi '111B IN39M AS INDIC "$ ax
<br />INS17RI:;4TIO IrC1I1 'T7IJ11,C)CAL t1CIENC HIS
<br />'"nie county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242"1. The
<br />facility member may bew".assigned by the local agency; however, this number must be "numerical and cannot contain an alphabet, If
<br />the local agency prefers the State M)ard to assign the facility number, please leave it blank.
<br />rr IS"11111 ASPONSII 1111'Y"OF 111 11..1" :, 1, tali "I1JXr INSP t 1 "I`IM FACILMY TO VI?RW 'I` M
<br />QAC` , C C31r `I1IIl3 INVORM STION. `MIS aAI"PU ° . '110 CANN(Yr BE Pittli(MMSSED tr'11I11 I3CM tYC;C ouisrr
<br />MBE IS ()"1` I11IsIM0 IN. 11111 LOCAL AGFN(7Y IS RESPONSIBIE1016111 C OMIALI;a"iIO OF ME 'MI)CAL
<br />AGFNCY US1? ONLY' INMRMAIJON 13OX AND1 311 FORWARDING ONE FORM 'A4 NT) A&V)C;1NJ1;11 FOR
<br />'13'(s O T111: aC).LIA ING ADDRESS.
<br />113111011" OF f!KIJ1fT)RNlfk,
<br />}
<br />11WNITA 1 )1 1 t� 3 V
<br />/o sm,fn1",Se
<br />I .O(IMC'MIER
<br />P.O. IM 527
<br />
|