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<br /> INSTRUCTIONS FOR COMPLETING FORM "Alt
<br /> GFINE RAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE,23,Cl IAPTl1`R 16,CALIFORNIA CODE OFREGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,D,V.ISI,ON 20,CALIFOICNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all N EW PERMIT'CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> I SUMIMITONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit.a facility plot plan to the local agency as part of the application showing the location of the'USTswith respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner must submit documentation showing compllan6t with state financial responsibility rcqluimmei is to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),CCR].
<br /> TOP OF FORM:"MARK ONLY ONE ITENT"
<br /> Mark an(X)in the box next to the iierri that best describes the reason the forni is being completed.
<br /> I. FACILITY/SITE,INFORMATION&ADDRESS(MUST BE COMPLETED)
<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.13OX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest CrOSS street and name of the operator.
<br /> 2. Phone number must have all area code. If the night number is the same,write"SAME"in proper locatiLmi.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS. I I
<br /> S. If Facility/Sac is located within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> If. PRO 11 l.-'RTY OWNER IN'FORM ATION&A 1)IDR ES S(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SEC TION 1;If the same,write"SMNIF,AS SITE"across this section. Tic sure
<br /> to check PROPERTY OWNERSI HP TY11[,.box.
<br /> 1,11.TANK OWNER IINFORMATION&ADDRI-.SS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME ASSI'll,"'across this section. Be sure
<br /> to cheek TANK OWNERSTY11L box.
<br /> IV.BOARD OF EQUA I-IZATION UST s'i'ORAG E I FEE ACCOUNT NU.M B ER(MUST'BE COMPLEI ED.SEE-ARTI CLE 5,Cl I A ly 11i P 6.75,
<br /> DIVISION 20 CALIFORNIA IIF'AL'I'll AND SAFETY CODE,)
<br /> Enter your Board of Eq tia I i,,,a ti on MOM)UST storage fee account nurnber which is required before your pcnnit allpiticalion -:iii be processed.
<br /> Registration with 1110,BOF,will ensure that you will receive a quarterly storage fee return in reeorling the S0.,,1Y16(6mills)I-xiillon fees duc on dic
<br /> nUrnbcr of gallons plaiccd it,your US I's. The 130L wi-11 code persons exempt from 1)33:illg the Aoragc foe so rclunis�i,ill no be s an.. if Yo`,LP,5 not
<br /> have an 3CCOL1111 M1111ber With Ilic BOF or if you have any questions regarding the(ec or exoniptions,please call tilt,130!3 at 910-3211 9669or wrilc
<br /> to the BOE at the following address Board of Equalization,Fuel Taxes Division,P.O. Box 942879,SaCralnC(110,(-7A 9 )1
<br /> V..PI IROLI:U.\I US I-J-41NANCIA 1.RLsTON SI Ill 1,1'1-y(MUST Bl--COMI)LF-111)[:OR I'l.-I im I'l: t1 I T.Sj',O'\
<br /> 1O,\S,)711 (ajifij
<br /> CODE
<br /> OF R 1:G ULATI ONS,)
<br /> ldcrl ll,cd by lhe owner and/or operat"'r,in meeting the Federal and State fill<ln,ial rcspollsil)iluy lc(lliwls ;ilI'S i's
<br /> any l"C c f o r slaw a b,;i I cy as w c 11 as norl Pei I olcu ril TJ STS are exempt front this I-x"u i 1 c 111 en 1.
<br /> VI.LEG A I.NO I'l LICA'1 ON AND 13 11-LI N G A 1)DR ES S
<br /> Ch c c k ON I:I 10 X I or 11 t-:Idl I I es s I h at Neill be used fo r 13 0 FI I LEG A 1,ANI)B111.1N G NO-1 11:1 CAJ 10A�S,
<br /> TANK OW N I-.R OK A I�'I I I OR IZED R F"PR FS ENTATIVF,MUST'SIGNAND 271
<br /> (a)(13)OI:'l1Tl,F23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.[
<br /> INSTRUCTION FOR"I']IF LOCAL AGENCIES
<br /> The county an jurisdiction numbers are Predetermined and can be obtained by calling the State Board(91(1)227,1303. r may 1x;
<br /> assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters.
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT is 'I III.' RESPONSIBILITY OFTITH LOCAL AGENCY THAT INSPECIS TIIL FACILITY '10 VI':RII-`Y THE ACCURACY OF THE.
<br /> INF OR-MA11O.N. TITSAPPLICATION CANNOT MB
<br /> BE PROCESSED IF THE BOH ACCOUNT NOT FILLED IN, T11FLOCAL
<br /> AGENCY IS RESP0,NSIBLE FOR THE comPi.,i,,TiON OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AN' D I-OR
<br /> FORWARDIN(3 ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE,FOLLOWING ADDRESS. THE LOCAL AGENCY SHOUTA)
<br /> RETAINTHE O1RI(.il-N*AIS AND FORWARDTHE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY'l HF,TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 393 FOR012OR1
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