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INS FRU(717IONS FOR CONIIII ONG FORM W
<br /> GF,NERAL B,15rizuc[IONS,
<br /> L Onc FORM A` shall be conqfticdl for all NEW PERWIN, l�ll'IRMI'I' ("II AN(;f,-S,»„ ,iiiN: FACILITY/SITE,
<br /> INFORMN11ON C'JIANOF&
<br /> 2, SUB MI'l' ONLY ONF (l� FORIS! Wfor a rcgardhess (,ffflic nunnbcic oi' tank,,, located iF 01c,
<br /> 3. The, form should be COMpIcted bv either tile H TMITAPPLICNIS'For 11w, LOCAL AGENCY
<br /> TANK INSIT"(70R.
<br /> 4, Ptense type or print Clearly all requested information,
<br /> 5. Use a hard pohn, wliing' you are making 3 copics,
<br /> I'0P OF FORM- ".MAIZK ONLY ONT” ITEM'
<br /> Mark an (X) in the box next to the item that best (1cecribes the reason the form is heing completed.
<br /> I. maury/smi,iiFORMNIDON & ADDRI-W% (MUSY BE C'OMPIJ4,110)
<br /> 1, Record name and address (phy"lica4 location) of file underground tank(s),
<br /> NOTE� Address MUT,51' have a valid physical locadon Including city. state, and zip cock;.
<br /> P.O. BOX NUNMI.,RS ARE N(YF ACCEYIA,1111�
<br /> Include nearest cross street and nanto of the operator.
<br /> 2, Phone number must have an area code. If the night, number is the same, write `1.3.AMT.`11' in Proper localion.
<br /> 3, Check the appropriate box for TYPF, Of' BUSINESS OWNERSHIP (ex. CORIPOI,NIION, iNI';TVII)UAI., etc,)
<br /> 4. Check the appropriate flox for TYPE OF BUSINESS.
<br /> 5. If Facilhv/Site is located withni an Indian reservation or other Indian trust lands, chock the box marked "YES",
<br /> 6. Indicate the NUMBER ofTANIKS at this SHY.
<br /> 7. Record the 11.P,A11) # or wrhe "NONE" in the space provided.
<br /> H. PROPEWIT OWNER INFORMK110N & ADDRfz-SS (musi, BE,cowurlv.D)
<br /> Complete alf items in this sectic"n, tulless all itclns arc the sante. as SIXTHI)N 1: if the same, write *SAME,AS SITE,'
<br /> (bil, scction, Be sure to chock PROPFIU-Y OWNLRS1 III, TYpI7,1 box,
<br /> 111, TANK OWNER INFORMN.11ON & ADDRE&S (MU,"'-I- BE COMPTIrITD)
<br /> Complete all items in this sevtionunles's all items are the same as SE(71710N 1; If the same. write *SAMII AS SY11' tactrcrss
<br /> this section. Be sure to check TANK OVINI:rR.S1111"ITPE,box.
<br /> IV. BOARD 017 M1JAL17AHON USF 9170RAGE HM ACCOUNr NUMBER(mlifsr BE CoMP11r.11a))
<br /> Enter your Board of'17/jualization (BOE) UST storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOT; will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0.006 (6 mills) per gallon fee due on the number of gAlons placed in your USTs. The BOE wilt code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have in account RUMIXt' With the 13011,", or ifyou have any
<br /> questions regarding the fee or exemptions, please call the BO' at 9[6-323-9S55 or write to the 130F, at aridn's"s:
<br /> Board of Equalization, Environmental Fees Unit, P.OBox 942879, Sacramento, CA 94279-0001,
<br /> V. PEI-I'ROIJ�.UM usr FiNANaAii,RBSPONSIBan-Y (mij,;r w co.-Anxri'la))
<br /> Identify the method(s) used by the owner and/or operator in meeting the Federal and Stile financial responsibility
<br /> requirements. US"T's owned by any Federal or State agency are exempt from this requirement,
<br /> VI. LEGAL N(YMq(:NFION AND B11 ENG ADDRENS
<br /> Check l2bl BOX for the address that will be used for B(Yp1J LEGALAND B111ING N01IF11CWHONS.
<br /> APPIACANr MUS`1'SIGN AN[) DNILI 11113 MRM AS INDICKIT,11
<br /> INSTRUCITON FOR'DfF LOCAL AGENCIES
<br /> The comity and jurisdiction nurnbers are, predetermined and can be obtained by calling the State Board (916)739-2421, The
<br /> facility number may be assigned by the local agency, however, this number trust be numerical and cannot contain any
<br /> alphabetical. If !he local a-ellcY prefers the State Board to assign the facility number, please leave it blank.
<br /> Tl'Ri'111E R ;ST ONSI13111IN OF 111H LOCAL AGFNC'Y T[IN17 INSPWIN'111E FACII-nT 1,0 VHMxY'111E
<br /> ACCURACY OF 111F, INFORMNITON. '11115 APPIA(WITON CANN(YI'BE PIZOCIASSED II?'1111f WE AC(X)UNI'
<br /> NUMBER IS NOT FILLED IN. 111E LO(AL AGUIN0f IS RESPONSIBLE FOR'111E COMPLE110N (;F 1111?
<br /> 'LOCAL AGENCY USE ONLY' INFO RM'DON I-X)X AND FOR FORWARDING ONE' FORM 'A' AND
<br /> ASSOCIYVIT0 FORM '11113' F0.1-LOWI NGADDRF-Rs—
<br /> S[WIT' OF CALIFORNIA
<br /> SI" IT WATER RE-SOURCES CONIMOL IX) RD
<br /> Oto s.WmI,:,P--.
<br /> DXrA PROCESSING CI-rq1T`,,R
<br /> P.O. BOX 527
<br /> PARAMOUW, CA 9M3
<br />
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