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<br /> INSTRUCTIONS FOR. COMPLETING FORM "At'
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TIT LE.23,CHAPTER 16,.CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTHAND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN USTOPERAIING PERMIT.PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2. SUB;1417 ON1..Y 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 arc 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 USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR).
<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)(11),CCRJj
<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 /> I. FACIIJI'Y/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 NUMBIiRS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number roust 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 BUSINIiSS.
<br /> 5. If Facility!,"itc is located within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> & Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.:1.I)Ff or write"NONE"in the space provided.
<br /> II. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETE]))
<br /> Complete all items in this section,unless all items are the same as SECTION l;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSIIIP TYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST"BE COMPLFTED)
<br /> Complete all iterns in this section,unless all items are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TY11L box.
<br /> lkl,BOARD OF rS', 5'f- _ :,US I 13L COMPI, CLE 5,CFIAIrTER 6.75,
<br /> DIVISION 20,CALI.FORdLA HEALTH AND SAFETY CODE.)
<br /> I nicr your Hoard of I quAizatient(13013)UST storage.fec acc;onmt number which is required before yoar permit algnareauor,czar be,111`0cesS(A.
<br /> Regisu<ntion with the 1301,wail ensure that you will receive a quarterly storage fee return in reporting the SW7Y)6((wr)t )i r;;,Alon n fee duc(7rt Lire
<br /> nurntncr of'gallons placod in your USI-s. Tl'ne 110E will code tx:rsons exernptfro.mn paying the storage fee so tt,u.urs t4-11 nkA.l;c s.a,t. if you dna net
<br /> hate,an account number v:ith the BOT:or if you have any questions regarding the fee or exemptions,plcaso call the 13().,a,9 10 3 22. 669 or write
<br /> to tine 130E at the follow azng address Bo::rd of Equalization,Fuel Taxes Division,P.O.Box 942K79,Sacran,s:t to,C,1
<br /> V. PhiROLl..L7M US IJENANCI.AL RIESPONSII KATY(MUS-1BE COG-11'Lli'CEI)FOR PE RO.I.I.J.NI USTs ONLY,SFT:SI Cl iCiNS 2711 60(8)
<br /> OF'1111,F.23,CI1AhiT R 16,CALIFORNIA CODE OF REGI LAIIONS.)
<br /> Iden ify the rtt.r_hexl(s}trsc i by t}ne owner and/or operator,in meeting tete Fe Lral and State financial responsibility rcticrr..,ni::rrts.US 1's 0-=11:cd by
<br /> any Foca•1 or State agency as well as n'xn-pctroienm UST's are exerrnpt from this requircnnent.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONEBOX for the address that will be u>ed for BOTH LEGAL AND I li I L'Yi N(.)TIFICA'110,XS.
<br /> TANK OWNER OR AUT110R,IZED REPRf SEN'I'ATIVIi (LIST SIGN AND DATE:T'IIL3.FORM AS INDICATED. (Slit?Sr;('I'ONS 2711
<br /> (a)(13)OF TITI.F 23 CHAPTER 16,CALIFORNIA CODE OF RI3GULAT IONS]
<br /> INSIRUC11ON FOR THI"LOCAL AGENCIES
<br /> The county an 3aris;,iictio n nunntxxs are predetermined and can be obtained by calling the;State;Board(916)227-1303. The.fa6ity rnumbcr Tray he
<br /> assigned by the local agcatcy;howcvcr,this number must he mrrnericA and cannot contain any alphabetical characters. If the:,local agency prelcrs
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS'iIII: RLsi o.,N51131LITY OF THE LOCAL AGENCY T]TAT INSPECTS THE FACILITY'10 VERIT=Y THE AC(a`RAC'Y OF THE
<br /> INFORMATION. THIS APPLICA'110N CANNOT BE PROCESSED IF THE I301?ACCOUNT NUMBER IS NOT FILLED IN. 'I'llli LOCAL
<br /> AGENCY IS RES110NSIBLE,FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFOR.IvIATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE:FOLLOWING G ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RET'AI.N'I11In;OR.IGD ALS AND FORWARDTHE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY'l IIF TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA.PROCESSING CENTER
<br /> 11.0.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 193 FOR012ORI
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