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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER Its,CALIFORNIA CODE OF REGULATIONS AND SECTIONS'25256.2525 7,AND 25259 OF CHAPTER
<br /> 6,7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> 1, One FORM"A°"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE:INFORMATION CHANGES.
<br /> 2, SUBN41T ONLY ONE-(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> S. 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 pian to thy'°local agency as pan of the application showing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711(a)($),CCR].
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as past of the
<br /> application for petroleum USTs[Section 2711 (a)(]1),CCR].
<br /> `IT)P OF FORM:"MARK ONLY ONE ITEM"
<br /> Clark aro(A-)in the box next to the item that best describes the reason the form is being ccur pleted.
<br /> 1, FACILITY/SITE INFORMATION&.ADDRESS(IMUST BE COMPLETED)
<br /> I. 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,OJ BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest cross street and name of the operator.
<br /> 2 Phone number must have an area code. If the might nunmer is the sane,write„"SAME"in proper locatiom
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex,t"ORF PRAT ION,INDIVIDUAL,etc,),
<br /> 4 4,'Chec.k'�he.�izpptopriate box for TYPE OF BUSINESS.
<br /> 5. ItFacilatyl5ite is located within an Indian reservation or tither 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,It3#or write"NONE"in the space provided.
<br /> II. PROPERTY OWNER INF°CIRSTA TIC/:;&ADDRESS(MUST BE COMPLETED)
<br /> Cornplete ai(items in this section,unless all items are the sane as,SECTION 1;If the same,write"SAIME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> 111,TANK OWNER INFORMATION&ADDRESS(VIL'ST°EIB COMPLETED)
<br /> Complete all teems 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 OWNERS TYPE box.
<br /> LV,BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.f5,
<br /> DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)UST storage fee account number which is required before your permit application can be processed,
<br /> Registration with the BOBwill ensure that you will receive a quarterly storage fee returns its reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt from paying the storage fee so returns will not be sent_ If you do not have an
<br /> account number with the BOE or if you have any questions regaadinsg the fee or exemptions,please call the BOE at 916-3112-9669 or write to the
<br /> BOEat the following address Board of Equalization,Fuel Taxes Division,P.CI,Box 942579,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY.SEE SECTIONS 2711 (a)(11)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,fit meeting the Federal and State financial responsibility requirements.LISTS owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL ANIS BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHOR17ED REPRESENTATIVE MUST SIGN AND BATE TETE FORM AS INDICATED, (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION FOR TETE LOCAL AGENCIES
<br /> The county and Jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4301 The facility number may
<br /> be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters, If the local agency
<br /> prefers the State Board to assign the facility number,please Leave it blank,
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO'VERIFY THE ACCURACY OF TETE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF"FELE BOB ACCOUNT NUMBER ISNOT FILLED IN, THE LOCAL
<br /> AGENCY IS RESPONSIBLE:FOR THE CONIPLEITON OF T'14E"LOCAL,AGENCY USE ONLY" INFORMATION OX. THE LOCAL
<br /> AGENCY SI-IC}ULD RETAIN THE ORICsINAI.AND YELLOW COPIES, THE FINK COPY SHOULD BE RETAINED BY T14E TANK
<br /> OWNER.
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