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<br /> INSTRUCTIONS "A"
<br /> GENERAL INSTRUCTIONS:
<br /> .S T 1V 2711 OF TITLE 23,CHA€'TER 16,CALIFORNIA£ .,I OF REGULATIONS °,°iii SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALTH AND SAFETY Cs REQUIRE OWNER` V)APPLY FOR AN UST OPERATING PERMIT,
<br /> 1, One FORM"A"shall be completed for all NEW FERMI f C°RANGES or any FACILI 'VISITE INFORMATION CHANCES,
<br /> 2. SUBMIT ONLY ONE(1)FORA"A"for a Facility/Site,regardless of the number of trunks located at the site.
<br /> 3. This fort should be completed by either the PERMIT APPLICANT or the LOCAL AC ENCY UNDERGROUND TAMC INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a Lard point writing instrument.you are ranking 3 caries,
<br /> 6. Tank owner must submit a facility plot.plan to the local , t n v as part of the appliczamn 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 cornph,"ince with state Financial rc;sponsibility requirements to the local agency as part of the
<br /> application for petroleum USTs tSection 2711(a)(!1),Ca Rjt
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an OQ in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACILITYISITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record nacre and address(physical location)of the underground tastk(s).
<br /> NOTE: Address MUST have a valid physics location including city,state,and zip code.
<br /> P.O.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 night number is the sacro,write"SALE"in proper locations.
<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 FacilitytSite is located within an Indiana reservation or caber Indian trust lands,check the box sharked"YES",
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> T Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> II. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the sauce is SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OT+r`i3 0 SHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all hones are dw same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 247,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Eyster your Board of Equalization(13013)UST storatge fee account nurztber which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure that you will receives quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your LSTs. 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 BOB or if you have any questions regarding the fee of exemptions,please call the BOE at 916-322-9669 or writs to the
<br /> BOE at the following address Poacd of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0601.
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEC SECTIONS 2711(a)(11)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULA`I"IONS,)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.USTs 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 haat will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM.AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA.CODE OF REGULATIONS,]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county-and jurisdiction numbers are predetermined and can be obtained by calling the State:Board(916)227-43(}3. 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 THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLET?IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL
<br /> AGENCY SHOULD RETAIN TIME ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER.
<br /> 6195
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