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INSTRUCTIONS FOR COMPLETING FORM "A" GENE INSI'RUCTIONS 1, One FORM "A" shall be completed for all A�III`4V•PERmns, PE3RM17F C:IIANGES or any FACIl,rI'Y/SPIV ENI ORMAVION(MANGES. 2, SUBMIT"ONE,Y ONE (1) FORM "A" for a FAity/Site, regardless of the number of tanks located at th, 'I'his farm sbould be completed by either the PERMIT APPLIC✓1N'I°or the LOCAL AC;I.TI(Y I NU1:R(;ROt.JND TANK INSPI CFOR. #. E'lease type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARK ONLY ONE ITEM" Mark an (X) in the bob.next to the item that best de�cribes the. reason the form is being corfrpteted. I. IrACEL,rI'Y/,SITE=INPORMAT ION &ADDRESS(MUST BE C,OMPIPTED) L Rvord name and address (physical location) of the underground tank(s). NOTES: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NCXI'AC(:EI'I:ABI.Ir Include nearest cross street and name of the operator. 2. Phone number must have.an area code, If the night number is t4e same, write "SAME" in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'T'ION, INI)IVIT')UAE„ etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands. check the boor marked "YFS". 6. Indicate the NUMBER of'TANKS at this SPIE. 7. Record the E.P.A. ID # or write "NONE" in the space provided.. H. PROPERTY OWNER.INIk)RMXf70N&ADDRESS (MUST'BE C OMPLE'TD) Complete all items in this section, unless all items are the same as SFCT'ION :I; if the same, write ",SAM.E.AS SPIV aeruss this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER NFO ATTON &ADDRESS (MU,Sr BE COMPL,una)) Complete all items in this Section, unless all items are the same as SE;CHON l.; If the same. write "SAME, AS SITE taero5s this section. Be sure to check TANK OV"'9 SL11P TYPE box. IV. BOARD OF EQUALMN11ON UST SFO GE FEE ACCOUNT NUMBER(MUSY BE COMPI.I:11-.D) 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 rvp>rti.ag; the $0,006 (6 mills) per gallon fee due on the number of gallons placed in your LiSI's. "The BOE 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 B0E; or if you have iany questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-(MOL V. PETROLEUM UST FINANCIAL RENPONSIBUXIT(MUST ISE?COMP1,I:1141)) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements, UST's owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NOTIFICATION AND BUJU NG ADDRESS Check ONE BOX for the address that will be used for 13071 LEGAL AND BILI M NO`IMCA'nONS. APPLJCANT MUST MGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR 1I3EE LOCAL.AGEFANCIP,S e 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 1III3 RFSPONSIB&M OF THE LOCAL ACY124CY TIIA"1'INS :,M TME FACIIdIY 7`0 VI'.,IU Y'nfu A(X''URACY OF TIIE INFORMN1710N. THIS APPIKA:TION CANNOT HE PROCINSE D W"IF HOFS ACCOt mr NUMBER IS NOT FILLED IN. THE IAX;AL AGIM.T IS RESPONSIBLE FOR T7•IE COMPLE.rnON OF TATS "LOCAL..AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "B"(s)TO TI•IE FOLLOWING ADDRESS. STATE Of?CALIFORNIA STATE WA37:R RESOURCE'S C:ON1:1t0I, BOARD C/O&Wjui P a. . DATA PROCESSING (MMIUR P.O. BOX 527 PA.RAMOUNr, CA 90723