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INSTRUCTIONS FOR NG FORM " "
<br /> GENERAL INSTRUCTIONS:
<br /> SECTIO i 271 I OF TITLE 23,CHAPT R 16,CALIFORNIA CODE OF REGULATIONS IONS A1ND SECTIONS 25286,25287,AND 25259 OF CHAPTER
<br /> 6.7,DIVI$10'N 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPt,'t`'FOR AN UST OPERATING PERMIT,
<br /> 1. One FORM":A"shall be completed for all NEW PERMIT CHANGES or any FzACILITYISITE INFORMATION CHANGES.
<br /> 2, SUBMIT ONLY ONE(1)FORM„A"for p Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should bne completed by either the PERMIT A PLICANT•yr the L..00AL,AGENCY UNDERGROUND TANK_INSPECTOR.
<br /> 4. Please type or print clearly ail requested information. _
<br /> 5. Use a hard Point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of the application sh€rving'the location of the USTs with rest to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner must suhanit afocumentation s owing compliance with state financial responsibility requirements to the local agency as past of the -
<br /> application for petroleum USTs[Section 2711 (a)(I1),CCR[.
<br /> TOP OF FORM. MARK ONLY ONE ITEM"
<br /> Mark an(%)in the box next to the item that best describes the reason the Parra is being completed, a
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<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 /> RO,BOX NUMBERS ARE NOT ACCEiPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area clone. If the night number is arc sarnc, wrote"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/She is located within an Indian reservation or other Indian test lands,check the box marked"YES",
<br /> 6. Indicate the NUMBER ofTANKS at this SITE.
<br /> 7. Record the E,P,A.IO#or write"NONE"in the space provided,
<br /> I1. PROPERTY OWNER INFORMATION&ADDRESS(MUST"BE COMPLETED)
<br /> Complete all items in this section,unless all iten;s art the same as SECTION I;If the satire,writs;"SAME AS SITE"across this section, Be sure
<br /> to check PROPERTY OWNERSHIP TYPE hex.
<br /> III.TANK CM,NER INFORNT AT"IO?N sot ADDRESS(1k USllI BE COI IPI.,ISTTD)
<br /> Complete ail hems itl this section,unless all items etc the some as SECTION l'.If the carne,write"SAME AS SITE"across this section, Be sure
<br /> to check TANK OWNERS TYPE box,
<br /> TV.BOARD OF EQUALIZATION UST S TORAGE FEE ACCOUNT NUMBER BER(MUST BE COMPLETED.SEE,ARTICLE,S,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST storage fee account number which i;required before your permit application can be processed,
<br /> Registration with the BOE will enswe thanyou will rt csve:a quarterly storage fee return in r;portin,g the per gallon ice due on the number of
<br /> gallons phaced in your UST„. The BOB will code persons exempt from paying,tut storage fee so returns will net be scnt. If you do not have an
<br /> account number with the BOE or of you have any questions,retarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOE at the following address Board of Equalizations Fuel Taxes :Tiwis€on,P.O.Box 942879,Sacramento,CA 942'79-0001. m
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUSTBE CC3MlL.E'T°E 9 FOR PETROLEUM UST's ONLY,SEE SECTIONS 2111 (a)(11)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify tate methods)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.LISTS owned by
<br /> any Federal or State agency as well as non-petroleum UST's are exempt from this re€uirernem,
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Cheek ONE BOX for the address that 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)(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 ea?ling the State Board(9I6)227-4301 The facility number may
<br /> be assigned by the local agency,however,this number most be numerical and cannot contain any alphabetical characters, If the local agency
<br /> prefers the State Board reassign the facility number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF TACH LOCAL . G,FNCY THAT Ps,,IPEC S THE FACIT.I `c'TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED 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 /> 6'95 •
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