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INSTRUCTIONS FOR COMPLETING FORM "Alf
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE.23,CI IAPTER 16,CALIFORNIA CODE,OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN US-11 OIIE RATING PERMIT.
<br /> V� One FORM"A"shall be completed for all N EW PERMIT CHANGES or any FACILITY/SITFINFORMATION CHANGES.
<br /> 2, SCBMIT ONLY 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 /> S. 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 pan of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCRI.
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. 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.BOX NUMBERS ARE NOT ACCETTABLE.
<br /> Include nearest cross street and name of the operator,
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location.
<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.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER of,rANKS at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> I.I. PROPI.-'.IZI'YOW.\;I-'IZINI-'OR.MA'D.ON&Al)!)R[:SS(.\,IUST13ECOMPI,EIT,.D)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the sarne,write"SAME AS SITE"across this section. lie sure
<br /> to check PROPERTYOWNE.RSIIIPTYPL box.
<br /> Ill.TANK OWNER INFORNIATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all iterns in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNLRSTYPE box,
<br /> IV,BOARD OFEQUALIZATION I.TS-f STORAGE FLE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLI, 5,CIIAIyI1;R 6.75,
<br /> DIVISION 20,CALIFORNIA 11FALT11 AND SAFETY I-Y CODE.)
<br /> 1`11WT your Board of Equalization(BOE)USTstoragc fee account nurnbcrwhich is required before your pennit application r.an be proccscd.
<br /> Registration with the BOE will ensure that VOU will.receive a quarterly storage fee return in reporting the S0.W6(6wilM)1,cr gallon fee due othe
<br /> nUrnbcr of gallons placed in your US I's. The BOE will code persons exerript from paying the storage fee so returns will' n nm be If you do not
<br /> h:)vc.an account number with the BOL'or if you have any questions regarding the fee Or CX01111)00118,please C311 the B01",at 916 3'r2-9669 or write
<br /> to the BOE at the follow ing address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 9.4279-000 1.
<br /> V. PE"TROLUUM UST FINANCIAL RESPONSIBILITY(MUSTBE.COMPLETED FOR PE I-RO1,11UNI LJSTs ONI Y,SFI:SFCI IONS 2711 (a)(S')
<br /> OF'11TI.J.,.'23,CI 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the 1110110d(S)used by the,owner and/or operator,in mccung the Federal and State financial 1-CSI)OOSibility re.yuircuicrnts.1.1*STS ONVIK'A by
<br /> any Federal or Staicagcncy as well as non-petiolcurn USTs are exempt.from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONEBOX for Ilic address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER ORA U11 I ORIZEID REPRESENTATIVE MUSTSIGN ANI)DATIi TI I E FORM AS IN DI CATI:1). (SJ:FSECl'I()NS27ll
<br /> (a)(13)OF TITLE 23 CIIAIIFER 16,CALIFORNIA CODE OF REGULATIONS]
<br /> LNS'IRUCTION FOR THE LOCAL AGENCIES
<br /> The county An jurisdiCti(.11 11LIVINUrs are predetermined and can be obtained by calling the State Board(916)227-4303. The I acdoy nurnber may be
<br /> assigned by the local agency;however,this number trust be numerical and cannot contain any alphabetical characters. If the local agency prefors
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT is RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY '10 VERIFY THE ACCURACY OF THE
<br /> INFORMATION. TI[IS APPLICATION CANNOT BE PROCESSED IF TILE BOB ACCOUNT NUMBER IS NOT FILLED I.N. TILE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE comm-F-rioN OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDAN()'ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO T1113 FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAINTIIIS'ORIGiLNALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRF.SS.THE 111NK COPY SHOULD BE
<br /> RETAINED BY]III;TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O&W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723 FOR0120RI
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