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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS'25286,25287,AND 25289 OF CHAPTER
<br /> A!,DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LIST OPERATING PERMIT,
<br /> I, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/STTE INFORMA`T'ION 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$hould be completedby 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 paint writing instrument,you are snaking 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the LISTS with respect to
<br /> buildings and kmdmarks-[Section 2711 (a)(8),CCIR].
<br /> 7. Tank towner must eubrait documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for Petroleum USTs[Section 2711(a)(t 1),CCI;],
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the itern that best describes the reason the form is being completed.
<br /> 1. FACILITY/SFFE 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.CO.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,writes"SAME""=°n 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 gated within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7, Record the E.P,A,ID It or writ's:,"NONE"in the:space provided,
<br /> II. PROPERTY OWNER INFORMATION pit,ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,,unless all iterns air the same as SECTION 1:If the sane,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> III.TANK 6WNER UNFORNIA"LION cit ADDRESS ,l'n IJS ' 3E CoMPI.,E TED)
<br /> Complete all items in this wction,unless all items are the same as SECTION 1e If the sane,write"SAME AS SITE"across this section. Be sure
<br /> to check TAMS OWNERS ERS TYPE;box.
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE1 LIST storage fee,accoant number which is required before your pennit appls`cation can be processerL
<br /> Regensure with the BOE will ensue that you will r�ceive a quarterly stt ram fee return its reporting the per gallon fee dice on the number of
<br /> gallons placed in your USTs_ The BOE will rode persons exempt from paying the storage fee so returns will not be sort. If you do not have an -
<br /> acLtount number with trio BOE or i;you have any questions regq rdm'2 the fee or c x,ulpt ons,please call the BOE at 916-322-9669 or write to the
<br /> BOE'at the following address Board of E ualizatiou>Fuel Taxes Division,P.CI,Box 942879,Sacramento,CA 94279-0001.
<br /> V, PETROLEUM LIST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED 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/or operator,in meeting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as non-petroieazn 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 AND DATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br /> (a)(T3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> a.]
<br /> INSTRUCTItON 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 recast be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number,please leas=e it blank
<br /> IT IS THE aRI SPOINSIBILIT"Y OF THE LOCAL A ,EN1 , §HAT l ,,h E, iS THE ""ACT..FFY TO VERIFY TI IE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNCOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY IS ILESPONSIBLE FOR THE COMPLETION OF THE "LOCAL,.AGENCY USE ONLY" INFORMATION BOY_ THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL.AND YELLOW COPIES. THE PINK COPY SHCOULD BE RETAINED BY THE TANK
<br /> OWNER.
<br /> 6/96
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