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INS-IRUC`I70N,S FOR tai) MP11. 11PW 'A'
<br />as
<br />GENERAL IN5I'RUC`nONS.
<br />L One FORM 'A' shall be completed for all,N13W PE us, PERMTF01AMGI S or any FA(mrrypsrm
<br />impoRmimON CHANGES.
<br />1 SUBMIT ONLY ONT, (1) FORM 'A. for a Fqci[ity/Site, regardless of the number of tanks located at the site,
<br />1 This form should be completed by either the P FFAPPLICANr or the LOCAL AGENCY UNDI.i*RGROUNDPANIC
<br />INSPEX'FOR-
<br />4. Please type or print clearly all requested information.
<br />5, Use a hard point writing instrument, you are making 3 copies.
<br />TOP OF FORM: 'MARK ONLY ONE' . ]REM'
<br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />I. FACIIrI-Y/STTE INFORMATION & Ar)I)Rll-%S (MUST up. a)Mpmu))
<br />1. Record name and address (physical location) -of the underground tank(s).
<br />NOTE: Address MUST' have a valid physical location including city, state, and zip code,
<br />P.O. BOX NUMBER.,AM3, Nbrf AC(M]PTABIX-
<br />Include nearest cross street and name of the operator.
<br />2. Phone number must have an area code. If the night number is the same, write "SAME" in proper loraiion.
<br />3. Check the appropriate box for TYPHI OF BUSINESS OWN1:1611111 (ex. COIRPORA`110N, INDIVIDUAL, etc.)
<br />4. Check the appropriate box forTYPE OF BUSINF-SS.
<br />S. If Facility/Site is located,on land within an indian reservation or other indian trust lands, check the box marked "YFIS.
<br />6. Indicate the NUMBEP, of TANKS at this SITE,
<br />7. Record the E.P.A. 11) # or write 'NON13in the space provided.
<br />11. PROPERTY OWNER INFORMA-110N & ADDRUSS (MUST' BE COMI`11:'I`ED)
<br />E Complete all items in ti -is section, uniess all itoras are the same as SEC -110N 1, if the same, write 'SAME AS Sr1'I1* across
<br />this section. Be sure tc check PkOlIF'RTY OWNF"RSHIPTYPE box.
<br />1. Complete all items in this section, unless all items are the same as SF C'I'ION 1, If the same, write *SAME AS SME"
<br />across this section. Be sure to check 'TANK OWNERS1111"I'YPE box,
<br />IV BOARD OF tX)`CJAJJ7JVI10N U."N',51'ORAGE 1411 ACCOUNT' NUM11F-,R (MUSF1111 (X)MPIrI7ED)
<br />Eracr your Board of FAluatization (1013) USr storage fee account number which is required before your permit application can
<br />be processed. Registration wth the B(;i,, will ensure that you will receive a qutrtcrly storage fee return in reporting the 50,006
<br />(6 mills) per gallon fee due on the number of gallons placed in your USPS. The BOT3 will code persons exempt from paying the
<br />".
<br />storage fee Sr returns will not sent. If -you do not have aa wcount number with the BOI or if you have any questions
<br />regarding the fee or exempzicns, please cal I I the BO' at 916-7.39-2582 or write to the BOE at the following address: Board of
<br />Equalization, Environmental Fc��s Unit, P.O. Box 942979, Sacramento, CA 9427940. 1.
<br />K IJ[XiAl, NO11FICKIION ANT) IIIIJING ADDRKSS
<br />1, Check ONE I31OX for the address that will be used for W171 I.EGAL AND 11111ING, NamwATiONS.
<br />APPLHAMI'MUST SIGN AND DAIT"'17111 FORM AS INDICATIR1
<br />INS71`RTJC`I1ON FORATIE LOCAL AGINCIES,
<br />'11he county and jurisdiction nembers are predetermined and can he obtained by calling the State Board (916)739-2,121. '.Me
<br />facility number may be assigned by the local agency; however, this number must be numerical and cannot contain ail alphabet. If
<br />the local agency prefers the State Board to assign the facility number, please leave it Illank.
<br />IT IS T1113. RESPONSIBILITY OF TIIE IX)CAL AGENCY ITISr JNSPWr-S TIJLT FACIMT TO VERIFY 11 W,
<br />ACCURACY 01711111 INFORMATION. IIIIS APPIJCXPTON CANNOT BE PROCF-W-1,13 IFIIIE BOLT ACCOUNT
<br />NUMBYM IS NO717 IqI1J. D IN. 11 IE IXW-At, AGI?WTY IS RESPONSIBIE JPORTT IF, t.OMPM. ION OF 11 IF "LOCAL
<br />AGENCY USE ONLY* INFORMN11ON IK)X AND FOR FORWARDING ONE FOR A* AND ASSOCIATED FORM
<br />,w(s) Twnw FO1J,OWING ADDREN&
<br />(;I'IVIF OF CAIAMRNIA
<br />WA`17ER RESOURCES CO FROL I )A D
<br />C/o S.W.Iulps.
<br />DXI'A PROCIISSING CENTER
<br />P.O. 13OX 527
<br />PARAMOUNT, CA WM
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