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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA COBE QRREGULATIONS AND SECTIONS"_5286,25247,AND 25289 OF CHAPTER
<br /> 6:7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(l)FORS"A"for a Facility/Site,regardless of the number of tanks lactated 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 making 3 copies.
<br /> 6. Tank owner mustsubmit a facility plat plan to the local agency ars part of the application shriwing the,location of the USTS with.respect to
<br /> buildin and landmarks(Section 2711(a)(4),CCR].
<br /> Wank o 'ger must submit documentation showing compliance with state financial responsibility requi€emcnts to the local agency as part of the
<br /> application for petroleum USTs(Section 2711(a)(I 1),CCR].
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the items that best describes the reason the farm is being completed.
<br /> I F'ACILf rY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. 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 /> I€tclude nearest cross street and name of the operator.
<br /> 2. phone number hoist have an arca-code. If the night;number is the''sarne,write„SANTE'"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 sharked"YES".
<br /> & Indicate the NUMBER of TAt>t1GS at this SITE.
<br /> 7, Record the E.P.A.Iia#or write"NONE"in the space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless ald,iterns are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sari
<br /> to check PROPERTY OWNERSHIP TYPE box:
<br /> ITE.TANK Cat&"NER INFORMATION&ADDRESS(MUS'TBE COMPLETED)
<br /> Complete all items in this section,unless all itemtsWe the same as SECTION 1;if the same,write"SAME AS SITE"across this section. Be sure,
<br /> to check TANK OWNERS TYPE box.
<br /> Int,BOARD OEEQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE S,CHAPTER 6.75.
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODED
<br /> Enter your Board of Equalization(BOE)UST storage Pee account number which is required before your perstaii application can be processed,
<br /> Registration with the BOE will ensure that'}bu 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 personas 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 or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> -'BOE;at the following address Board of Equalization,Fuel'Taxes Division,P,O,Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM LSTs ONLY.SEE SECTIONS 2.717 (sa)(1 I)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the methods)used by the owner and/or operator,in meeting the Federal and State fmahciel responsibility requirements,USTs owned by
<br /> any Federal or State agency as well as nom-petroleums USTs are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONITBOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANIS DATE THE FORM AS INDICATED. (SEE SEC"T"IONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUC"I CSN 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 character;. 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 VERIFYTHE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER t N&FILL-ED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE `LOCAL AGENCY USE ONLY" INFORMATION BOX., THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> 6,19s
<br />
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