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,t S'IRUC HONIS FOR COMii LE71"INta FORM "A" i GENERAL INS'E"RUC-I 1ONSa 1. One I,'ORM "A" sh.:: be completed for all NEW PER I , PE? I"I°CHANGES or any 1°rt(:il.l"Iy/:119; aNPCDWA"I ON Ca ANCl$1ms. 2. SUB 1°ONLY ONE(1) FO "A"for , I aci(ity/`site to r,ardle ss of the number of tanks located at tl3 site. I This form should be completed by cit ie:r the or tate LOCAL;AGENCY i.%NDI�.RGROI,IND TANK IN SPI;,C"I OIL 4. Please type or print clearly all requested information. 5. ,Use a hard point writing instrument ,ou ave, making 3 copi..s> 'I'CAI'OF I IC .- "MARK ONLY ONE M" Mark an (X) in the box next to the item that: best describes the reason the form is being completed, L FA6:TE:WY/SITE `70 ADDRESS (M ST BE CCAMPf.R110) 1. Record name and address (physical locaeiott) of the undergtoundi tank(s). NOTT": Address MUST have a valid physical location including city, stage, and zip code. P.O. BOX NUMBERS ARR NUFccia—I' Cma Include nearest cross street acid name of the operator. 2. Phone number must,have an area code. If the night number is the same, write "SALMI;" in proper location, 3. Check the appropriate box for TYPE OF BUSINESS C3'4U1V1~'ICSHIP (ex. CORPORATION, INDIVIDUAL,, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/site is located within an Indian reservation or other Indian trust ]adds, check the:box marked "YES". ". 6. Indicate the NUMBER of'TANKS at this SITE. ?. Record the E.P.A. IIA # or write "NONE" in the space Provided, 11° PROPERrY OWNER WK)RMAMON&ADDRESS (MUST BE I:rt, Complete all itetus in this section, unless all items are the sante"as SECTION 1, if the saltie, write 'SAME AS Will" across " this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWN14R INFORMATION &ADDRESS lMusT BE compI IIIA) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME.AS SI'I'I across this section. Be sure to check TANK CI IIIA TYPE box. Ili. BOARD OF EOUALMATION LT. ,1;M GE?FEE ACCOUNT BER(MUST BE cO PI En ) Eater your Board of Equalization (Bf?I,) USI- storage fee account number which is required before your permit application can be processed. Registration with the 130E wall 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 I.IS"1's. The BOB will code persons exempt from paying the storage fee so returns will not be sent, If you do not have an account number with the BOB or if you have any questions regarding the fee or exemptions, please call the BOB at 916-323-9555 or write to the TIME at the following address: Board of Equalization, Environmental Dees Unit, P.O. Box 942579, Sacramento, CA 94279-17001. V. I'LrF'ROLEUM UST FINANCIAL SES S 1I.. (MUST 13E CCA rIED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. US°I's owned by any Ipederal or State agency are exempt from this requirement. VL LEGAL IO 'IC AT ION AND BHJ JNG ADDRESS Check ONE BOX for the address that will be used for BOTH HCIAL AND BILUNG N(YIUqCX110NS. P11 F°MU,qT SKIN AND DATE'llffil FORM AS INDICAIVD. S'IIEEIC, CANT FOR THE LOCAL AGFNCIES Ile county and jurisdiction numbers are predetermined and can be obtained by railing 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°11113 t II "1 Y 0117771W LOCAL AGENCY'I F1AT INSPW. FS' 1IR FACHIPY TO '111F ACCURACY Olp'17113 INFORMNITON. TIHSAPPLICA'11ON CANNOT BE PROCESSED IF 11IF BOE ACCOUNI' NUMBER IS NOT FI1,I,ED IN. 11W LOCAL AGENCY IS RESPONSIBIX.FORT14F.COMPLETION OF.THE "LOCAL AGENCY ASIA ONLY* INFORMiVnON BOX AND FOR FORWARDING CANE - "A"AND AS.SO . 119) FORM "13"(s)TO 'I71E IZOLLOWING Al DI?R STATE, OF CALIFORNIA S`T'ATE WAFER RESOURCES CONTROL BOARD C/O S * a ..5 P.O.DATA PROCESSING CEN11M BOX 527 PARAMOUNT, CA 90723