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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE 23,CHAPTER 15,CALIFORNIA f .=Of REGULATIONS t`=,ND S CTIONS 25285,25287,AND 2-5289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFE'T'Y CC D"E REQUIRE OWNERS".P.)APPLY FOR AN UST OPERATING PERMIT.
<br /> I. One FORM"A"shall be completed for all NEW P RMI`I'CHAN ES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT 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 /> 5. Use a hard point writing instrument,you are Snaking 3 cot:t,°�„
<br /> 6. Tank owner roust submit a facility plot plan to the local ,;ar?cy 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 comply nce with state Financial rr s'pgnsibilits requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),,C:C R .
<br /> TOP OF FORM;"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the mason the form is being completed.
<br /> I. FACILITY/SITE INFORMATION&ADDRESS("MUST BE COMPLETE-].))
<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 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 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 TANKS atp SITE.
<br /> 7. Record the E.RA.ID#or write"N C)N -;;stn she spade provided.
<br /> IL PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unles4.611 items are the same as SECTION 1;If fhe same,write"SAME AS SITE"across this section_ Be sure
<br /> to check PROPERTY OWNdER HIP TYPE box.
<br /> Ill.TANK OWNER INFORMATION;&ADD 'SS(MUST BE COMPLETED)
<br /> Complete all iters in this section,rudess.all items are the same as SECTION 1,If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TALK OWNERS"T'YP'E box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE,ACCOUNT NUMBER(MI UST BE COMPLETED,SEE ARTICLE 5,CIIAPTRR 5.75,
<br /> DIVISION 20.CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your hoard of Equalization(FOR)U int"storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure that ru will receive a quarterly storage fee return in 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 wilt not be sent. If you do not have an
<br /> account number with the BOE or if you have.-,my questions regarding the fee or exemptions,please call the BOE at 916-322-9559 or write to the
<br /> BOB at the following address Board of equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LIST FINANCIAL RESPONSIBI�ITY(MUST BE COMPLETER FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/6r operator,in meeting the federal and State financial responsibility requirements.USTs owned by
<br /> any Federal of state agency as well as non-peirialeum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDR SS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFI A'TIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANIS DATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CA LIFrORYIA COPSE OF REGULATIONS,]
<br /> INSTRUCTION/FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predet Ams'ned and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigned by the local agency;however,this nturalxw crust be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility nutti€Ser,please leave it blame,
<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 BOE.ACCOUNT NUMBER IS NOT FILLED IN. TIME LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOUL6 RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNIE e A
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