|
x7 v;w, a,-
<br />4;w, mm
<br />INSrRUCHONS FOR COMPLEA'ING i'ORM 'A'
<br />GFINEIRAT. INS-17RUCITONS:
<br />1. One FOlZM "A" shall be cornplctcd for ;+1! NEN,'PFRMI'1S fij-qmrr CHANGE -S or any FACILITY/S1,11"
<br />IN1,T)RAM11ON CHANGUN.
<br />2. SIAWFONLY ONE (1) FORM 'A -,Jr Facility/Sne, of the 111111'.ber of mill's Ioc'lfcd tag
<br />'Y 1JNl)ER0R(J-'NI)
<br />3, This form should he con1filctcd by cith-i� use;PFRMFF APPIJCANI' or the LOCAL AGENC
<br />TANK INSPECI'OR.
<br />4. Please type or print clearly all requesttJ in ormation.
<br />5. Use a hard point writing instrument, y,,u are making 3 ccipi(,:.
<br />TOP 017 FORN& 'MARK ONLY ONF 1'117M'
<br />Mark an (X) in the box next to the item tl:at ?,-st describes the :",,;;,n the form is being compicted,
<br />1. J?ACIJYI'Y11Sr1E IM-IORMNIION & ADDRESS (W Sr 13E COMPI, ITT))
<br />1. Record name and addre,,,, (physical of the undergr—m,.1 iank(s).
<br />NOTE Address MUST have a -valid �hv,"al location inclu(,,-:;iv state, and zip code.
<br />P.O. BOX NUM13FRS ARE 140.,' ACX3T]l'AM.1L
<br />Include nearest cross street ai c of the operator.
<br />1 Phone number must have an area code. the night number is the same, write "SAME' in proper location,
<br />3. Check the appropriate box for TYPE OF 'BUSINESS OWNERSHIP (ex. CORI10RA'I1ON, INL)WIDUAL, etc.)
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES".
<br />6. Indicate the NUMBER <;r TANKS at this SPIT.
<br />7. Record the E.P.A. ID # or write "NONE," in the space provided.
<br />H. PROPEICYY OWNEER INFORMNtION & ADDRF-SS (musr BE COMPLH-nTD)
<br />Complete all items in this section, unless all items are the same as SE.C710N 1; if the same, write "SAME &S SFI1n` across
<br />this section. fie sure to check PROPERTY OWNFRS1III1TYPE* box.
<br />111. TANK OWNEIR JNFORM/V11ON & ADDRE&S (W)ST RE COMPILrIVD)
<br />Complete all items in this scoi011; unless all items are the same as SFCI'ION 1: If the same, write '.SAMF' AS S]`W, acrk,;,h
<br />this section. Ile sure to check TANK O"ERS1111i"rYPE hox.
<br />IV. BOARD OF MUAIJZAIION U51' STORAGE 1EF ACCOUNT' NUMBER (MUST BF, comPlimix))
<br />Enter your Board of Equalization (BOF) UST storage fee account number which is required before your perinit applicition
<br />can be processed. Registratirm with the WE will ensure that you will receive a quarterly storage fee return in reporlm", the
<br />SO.006 (6 mills) per gallon fess due on the number of gallons placed in your U -51's. The BOF Aill code pcasons excinpi fiom
<br />paying the storage fee so returns will not be sent. If you do not have an account number with the BOE' or if you have any
<br />questions regarding the fee or exemptions, please call the BOF at 916-323-9555 or write to the BOE at the following a(Rlros:
<br />Board of Equalization, Environmental Fees Unit, P.O. Rox 992879, Sacramento, CA 9,4279-0001.
<br />V, ITTROLEUM USFFINANnAL RFSP0NSTB1LrrY (MIJEF HE COMPLITrED)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USIs owned by any Federal or State agency are exempt from this requirement.
<br />V1. LEGAL NCY11FICNITON AND B111ING ADDRESS
<br />Check ONE BOX for the ao&ess that will he used for BOTI1 LEGAL AND BtUJNG NOTIFICA'11ONS.
<br />APPLICANr MUST SIGN AND DATE THE FORM AS INDICA11-0,
<br />INS-IRUC-FION 17OR THE LOCAL AGENCIE-S
<br />The, county and jurisdiction numbers are predetermined and can be obtained b,, calling the State Board (916)739-242'1. 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 />rr IS nm RiN.-roNsimury oypw tOCAL AGENCY 1' %WRItry *1'111J
<br />ACCURACY 011711IF INFORMATION, '1111S APPLICATT':, T RF1SSYID 11"11111 WE' ACCOUNT
<br />NUMBI.,,'R IS NOT 111JED IN. 'ITIE LOCAL AGENCY -% AF F, E1111 COMPL111ON OF'Fill!
<br />'LOCAL AGENCY USE ONLY' INFORMNITON BOX 4AW0 k,: � "' A, ONE FORM 'A" AND
<br />ASSOCLA'17114-1) DORM 'W(s)T0 71114, FOILOWING ADDRESS-
<br />'Vr/V1` OF "JFORNIA
<br />SIWIT' WATER RFSOIJRC.
<br />We P.S.
<br />DA'I'A PRIOCESSING CEWFIR
<br />PO£ 1301IX 527
<br />PAR.AMOUN1', CA W-723
<br />
|