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INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: SI?CTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER . 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS I'O APPLY FOR AN UST OPERATING PERMIT. 1. One FORA"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORA"A"for a Facility/Site,regardless of the number of tanks located at the site.. 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. 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 buildings and landmarks[Section 2711 (a)(8),CCRI. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs[Section 2711(&)(11),CCR). TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the forth is being completed. I. FACILITY/SITE INFORMATION&ADDRF.SS(MUST BE COMPLETED) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O.BOX NUMBERS ARI:NOT ACCEPTABLE. Include nearest cross street artd name of the operator. 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.). 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is.located within an Indian reservation or other Indian trust lands,check the box marked"YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the I:.P.A.ID#or write"NONE"in the space provided. IT. PROPERT"Y OWNER INFORMATION&ADDRESS(MUST I3E COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III.TANK OWNER INFOR4IATION&ADDRESS(MUST BE COMPLE'T'ED) Cumliiete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check TANK OWNLRS TYh'L box, IV,BOARD OF ECILIAI._1ZAT ION USTSTORAGE,.FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAp-I,ER 6.75, DIVISION 2O,CALIFORNIA 111..,AL TTI AND SAFETY CODE.) Enter your Board of Liqual ization(1101:;)UST sturage fee account number which is required before yottr penriit application can be proccssed. Registration with the BOE will ensure that you will.receive a quarterly storage fee return in reporting the 1>0.(X)6(6wills)per gallon fee due on the nurnber of gallons placed in your LiS'I"s. Tltc 1:30L will code persons exempt from paying the storage fee so returns will not be scut.. If you do not have an account number with the.BOE,or if you have any questions regarding the fee or exemptions,please call the BOE at 916 3'22-9601)or writs to the BOE at the following address Board of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94279-0001, V. PI.iTROI.I:L\T USI'FINANCIAL RLSPONSIBILITY(MUST BE CONIPLET'ED FOR PITT ROI..EUNI USTs ONLY,SEE SFCI IONS 2711 (a)(1;) OF 111LE 23,CIIAP`ITiR 16,CALIFORNIA CODE,OF RI]GuLATIONS.) Identify the nlcthal(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility rcpt ircut:;rtts,USS , ni.A by any Federal or State agency as well as non-petroleum UsT's are exempt.from this requirement. VI.LEGAL.NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOT11ICATIONS. TANK OWNER OR AU"1'1101tIYI D REI'RESEN-I`ATIVE.MLJS'f SIC'iN AND DATE TIIE FORM AS IN DI.CATED. [SEE SI CIIONS 2711 (a)(13)OF'i".IfL.I:23 CIIAPI'ER 16,CALIFORNIA CODE OF REGULATIONS.] 1NS'IRUCIION FOR TI IE'LOCAL AGENCIES The county all jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4.303. 'I"hc facility number may be assigned by tile local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS THI RESPONSIBILITY OF TIIE LOCAL AGENCY THAT INSIrECT's THE FACILITY`10 VERIFY THE ACCURACY OFTHE INFORNIATION. TI ITS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILI.I D IN. THE LOCAL AGENCY IS RESPONSIBLE FOR TIIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDIN(.3 ONE FORM"A" AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN 7"HE Ok.IC.IINALS ANI)FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE REI"AIINED BY T HI:TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 3193 FORD12DRI �I