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<br />1NN MUC11ONS FOR COMPLI " I iNG PO KIM W
<br />GENERAL
<br />N, r•
<br />I. OOP\1 '%`,l" aIltdt 1 N1, f' &N ol, :wl AlF
<br />I N 1 40 R 3.%4 ATI 0 N CI I A N I -,'S
<br />2, SUBMI'I'ONLY ONE (1) FORM W,oi-� �A t
<br />3, Thi, lorm .,1ou!lj hc corio i-tu<l kv ,iibwr il,, ill J�Ml F ATIPLICANI or ilk" LOCAL Ato 711' NOFWIItO\
<br />tli
<br />D111
<br />TANK INSETCOR-
<br />(J 4, Tllc,Isc 'r pnnC!Catly all requust,,J
<br />Usbard ;,oint om ar(t
<br />TOP OF I -T'R'W-- "MAM ONLY ONE ITFM
<br />Mark an lX) in 11�c t,oX next to dvt, it&11,01'a bcsl descrO,e', lite mason the form is hc:nz,
<br />L FACILITY/SITF INFORMA-11ON & ADDI?jQ%S (MUST BU (-',OMPI+JmI))
<br />L IZe("Md r)anle ' rid addres=s (Physical location) f, flle undcrground
<br />Addn�,ss MU'ST Kiu�,'a �alid pllysic�d lo,�anmnn6ud'iml- cnV, "tali" and zq)
<br />PD. IM NUM.BE,WS ARE Nur ACUTYMBIli-
<br />Includ(, t,s crass street and name of ,,Pcrator.
<br />1 Phone maubc-1, mn, ai,ea codo. If the -wham is the sante, wilte "SAMI" in ;)ropc, loc,ilion,
<br />1. Check ills: approp; 'or 11' -A.NITSIIIP (ex. CORPORANON.
<br />4. Check tiro apf)ropn,
<br />5. If laciliiySne is lo�,,ii, r Indian trust lands. check i lie hox mm-kcd YI
<br />6, indicate thtc NUMBER
<br />7 Itccord dw, Y-P,A, 11) # r,€ `01IL" in the st,
<br />11, PROPERTY OWNER INFORM.- -,)DRUSS (Ws— — C'OMPLv'mI))
<br />Complcte 'al! ileml, in this sall kni's ar,; the sante as SI >CTTON 11 if Elic, same, write 'SAME AS ST H
<br />this section. Be sure to clicck P"'IRTY OWNEIRS11111 TYPF, box,
<br />ILC. TANK OWNER INITORMMION & ADDRE&S (MU,,Tl' HE C(3MPU.--mD)
<br />Complete all items in this section, Linless all items are the same as SFCFION� ll If the same. write `.e.AME'AS Srlt-
<br />this se0ion. Bit, sure to check TANK OVWNFJKSI1JP IYPE b(».
<br />IV, BOARD OF WIJALMMON USI` S70RAGE', ME AC(.X)UWI' NUMBf ?R (MUSU 111t COmiftmia))
<br />11MI, your Board of Equalizatroh (BOV) USTsiora c fee account mmibcr which is required bfore wur Permit np",!",I;
<br />carr lie processed, Registration with the BOF will cas%jm', that you will receive a quarterly storage fee return in -1-1)1'i',H,�, 11,
<br />$0.006 (6 mills) per gallon fee due on the number of IgAlons placed in yotir Lr 'j,,. The BOE will code Perscln", e,,t
<br />paying the storage fee so returns will neat. be sent. If you do not have in 3(Tounl number with the BOF or 11 w ;.l,c
<br />quesdons, regarding the fee or exemptions, please cadl the BOF at '916-323-9.5.55 or write to, the BOE the
<br />Board of EkItializatlon, Etvironmenial Fees Unit. P.O. Box 942879, Sacnattlemo, CA 94279-0(Y)I,
<br />V. P17FROLEUM Uil' FINANCIAL RE' SPONSIBIL1717Y (MU,';Tl- M., CC) MPLE-ITD)
<br />Identify the method(s) used by the': owner aadl/oil off etator in meeting the Federal and State financiai
<br />requirements. 11'51'4 o%vred by any Ftjcral or 'State agency are exempt from this requirement,
<br />VL LEGAL NUMICINFION AND DIIJING ADDRF&S
<br />Check ONE, BOX for the address that will be uscd for, E30111 11I (;AL, AND BILLING NMIMCNIJONS.
<br />APPLI(AN'r ML U SIGN AND DMETHE FORM AS INE)ICNITI),
<br />\4
<br />1NtiI.'.RU(-J1ON FOR111P LOCAL AGHINCIRS
<br />11'bc couniv and jvrisdiction iiumitcrs are predetcrninied and can be obtained by calling the State Board (916)739-242j, The,
<br />6ifii,y min,iber may be assiped by the local agency; b(lwe-ver, this number must be numerical and cannot contain anN,
<br />.,I _g
<br />alptialkirica", If' the local agency Prefers the Sime hoard to assign the facilio; number, please leave it blank.
<br />rr Is 'um I2I;?,S11()NsumnY oimm- LOCAL AGENCY TMNI' INSPlit'J'S THE FACImY TO VERIFY '1111'
<br />ACCURACY OEC 7111, INFORTAMION. MIS APITICA11ON CANNUF BE PROCUSSED IF1711I WE MCCOUNI,
<br />NUMBER IS NOT FILLED IN, '111E LOCAL AGENCY IS RESPONSHILP" MR111F COMPLE11ON 01131M
<br />'LOCAL AGP.*NCY USE ONLY" INFORMIMION BOX AN13 FOR FORWARDING ONE IURM 'A" AND
<br />ASSOCIMED FORM "B'(s)TO '111F, F011,0WING ADDRESS.
<br />STME OF (AIMORNIA
<br />9FJVM WA'ITIR RUSOURCES COWROL TX)ARID
<br />C/() &W,1U,-P-&
<br />DXIA PROCF-SSING CF1*N`I'E1R
<br />E0, 13OX 527
<br />PARAMOUNF, CA 90723
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