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?tu", k"''. ., ts 14 INSIRUC11ONS FOR CC7he PLE'FINC"s FORM "A" GENERAL IN,5TR1JCr1ONS: a FCR'M "A" shall be completed for all NEW PE rI , PFIRMrr C 1A F`-1;or any FAC°li.l"y/Sriv, -)PPI TON C:IE11NCiln`i, 2. SLSI mrr oNLY ONE (1) FORM "A"for a Facility/She, regardless of the number of tanks located at the site. sl c uld be completed by either the PER-MIT APPLICANT or the LOCAL AGEINCY UNE)I",E2CRIZC)UND TANK INSPECTOR 4. Please type or print clearly all requested information. 5, Use a hard point writing instrument, you are making 3 copses. P OF Ik)R m "MARK O Y ONE. , 'sRR" ',,,Lrk an (X) in the box next to the item that best describes the reasons the form is being completed. L I ACTIXI fS A PIPORMA110N&ADDRESS (MUST"BE c:OMPI.0 I"I7) 1. Record name and address (physical location) of the underground tank(s). NOTE": Address MUST have a valid physical location including*city, state, and zip code, P.O. BOX NU I? ?NCy.T ACCEP'rABLIL Include nearest cross street and name of the operator. I Phone number must have an area code, If the night number is the same. write ",AME" in proper location.' 3. Check the appropriatebox for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) 4, Check the appropriate box for TYPE OF BUSINESS, S. If Facility/Site is located within an Indian reservation or ether Indian trust lands, check the box marked YES 6. Indicate the NUMBER of TANKS at this SITE, 7. Record the E.P.A. ID # or write "NONE" in the space provided. IT. PROPEIrrY OWNER 170N&ADDRESSBE CO I UITO) Complete all items in this section, unless all items are the sante as SECTION 1; if the sante,.write "SAME S SrFll' across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III." TANK OWNER IN17ORMATION &ADDRESS (MESE;I°BE CO PIs 1 ) Complete all items in this section, unless all items are the sante as SECTION 1; If the same;write "a F,AS S1717F" across this section. Be sure to check TANK OVIWUMUP IWE box, TV. BOARD Ole EQuALjzAnoN usrsroRAGF,EER ACCOLI ER LST BE ) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the, $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE wrill code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the BOIL; or if you have any questions regarding the fee or exemptions, please call the BOE at 916-32349555 or write to the BOE at the following address: Board of&Iualization, Environmental Pees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PIrrROLEUM USr F04ANCIALRESPONSIBILITY (MUST BB CO t3) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. 1SSTs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NO`I`14CATION AND BILLING ADDRESS Check ON13 BOX for the address that will be used for BOTH LEGAL AND BH1,JNG NC)TH11 Po '17TO S. APP1J(ANr MIS sL'S"ICIN AND DATETHE FORM AS INDICATFIX INSI'RUCTION FOR THE LOCAL AGENCMS The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421, The facility number may be assigned by the local agency-, however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. IT IS ITIE RE-SPONSIBHXFY OF MEI LOCAL AGENCYIIIAT INSPEMTIIE?FACILITY TO VFMFY I1II; ACCURACY OF THE INFORMATION. THIS APPI,ICA'IION CANNOT BE PROCESSED IF THE BOE ACCOUMF NUMBER IS NOT FILLED IN. TEE LOCAL AGENCY IS RESPONSIBLE E :CO PLFE ION OFIE, 'LOCAL AGENCY USE ONLY* INFO [TON BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FO "B"(s)TO TFIE?FOLLOWING ADDRESS. . S'DVIM.<OF CA11FORNIA STATE WATER ° )L.TF2C. S CONTROL BOARD C/O S ' ? DXrA PROCESSING CI° ITIR P.O. BOX 527 PARAMOUNT, 90723