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<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CI-IAPT"ER 16,CALIFO NIA CODE OF REGULATIONS AND SECTIONS 2528 .2 287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,a°"�'ht.,Jf'CRNTA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR N CST€P R-AlI'°G 1~RMI`I",
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANCES or any FACILITY ISIT.E 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 forth 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 hand point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit a facility pleat pian 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 Racal agency as part of the
<br /> application for petroleum USTs(Section 2711(a)(71),CCR].
<br /> TOP OF FORM "MARK ONLY ONE ITEM"
<br /> Dark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> L 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 coda;,
<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,,trite;".S:M "an; sin°r lccatio
<br /> 3. Check the appropriate boy for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,I D k IDIJAL,etc.),
<br /> 4, Check the appropriate box for TYRE OF BUSINESS,
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"'YES".
<br /> S. Indicate the NUMBER of TANKS at this SITE.
<br /> T Record the E.P.A.ID=or write"NONE"in the space provided.
<br /> 11, .PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1 If the same write"SAS",E AS SITE`across this section. Be sure
<br /> to check PROPERTY OWNERSHIP NERSHIP TYPE box,
<br /> III,TANK OWNER INFORMATION&ADDRESS(NTUST BE COMPLETE[))
<br /> Complete all items its this section,unless all items are the same m SECTION I,If the sarrre,wr t "SAME AS SITE`across this section. Be surf;
<br /> to check TANK OWNERS TYPE.box.
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTCLE 5,CHAPTER 6,75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND 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 BOB will ensure that you will receive a quarterly storage,fee retusan in reporting the per galloon fee due on the number of
<br /> gallons phased in your LISTS. The BOB will code persons exemptfrompaying the storage fee so returns will not be sent_ If you do not have an
<br /> account number with the BOB or al"you have any questions regarding the fee or exemptions,please call the BOB at 916-322.9669 or write to the
<br /> BOE at the following address Board of Equalization,Fuel Taxes Division,P.£),Box 942579,Sacramento,CA 941279-0001.
<br /> , PETROLEUM US l FINANCIA1. RESPONSIBILITY(MUST 3E COMPLETED FOR PETROLEUM USTs I s iiNLY.SEC SECTIONS IONS 2711 (a)(l 1)
<br /> F TITLE 23,CHAPTER 16,CALIFORNIA COBE OF REGULATIONS,)
<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 that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN,ANIS DATETHE FOO--,' l AS INDICATED, (SEE SECTIONS 2711
<br /> (a)(13)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)227-4303. 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 CIL°THE LOCAL, AGENCY T14AT INISPECT:S THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF't HE BOB A€:rC;tTTJNT?ti1t;MBER IS NOT FILLED IN, THE LOCAL
<br /> AC:sENCMY IS RESPONSIBLE FOR THE COMPLETION OF°I HE "LOCAL AGENCY USE ONLY°' INFORMATION BOX, THE LOCAL
<br /> AGENCY SLIC)T.s"LD RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> 6t�5
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