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INSTRU NS FOR COMPLETING FIM "A.It
<br /> GENERAL INSTRUCTIONS:
<br /> SECIION 2711 OFTITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEAl-TI I AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERNFING PERMIT,
<br /> 1. One FORM"A"shall be completed for-all NEW PERMIT CHANGES or any YACILITY/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 making 3 copies.
<br /> 6. Tank owner must submit a facility plot.plan to the local agency as pan of the application showing the location of the USTs with respect to
<br /> buildings and lan—Imarks[Section 2711 (a)(8),CCRI.
<br /> 7. Tank owner mwlL submit documentation showing compliance with state financial responsibility requirements to thelocal agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(11),CCRI.
<br /> TOP OF FORM:"MARK ONLY ONE ITE'A-
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACII.1TY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical.location)of the underground tank(s).
<br /> NOTE: Xddress 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 TYPL 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 at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in die space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ADDRI-�SS(MUST BI--COMPI-rTEI))
<br /> Cornplete all items in this section,unless all iterns are the same as SEC`IION 1;If the same,write"SAME AS SITE`across this section. Be sun-,
<br /> to check PROPERTY OWNERSHIPTYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPlYTED) I S SITE"across this section, Be sure
<br /> Complete all items in this section,unless all items are the same as SECIION 1;If the sarne,write"SA.N IF A
<br /> to check'I'ANK OWNFRSTYTl:box.
<br /> IV.BOARD OF EQUAL_ LIS I'SIORAGE FEI.,ACCOUNT NUMBER(MUST"BE COMP LEITH.SEE ARTICLE 5,CIIAVITR 6.75,
<br /> DIVISION20,CALIFORNIA AND SAFl-TY CODE.)Filter
<br /> DIVISION 20,
<br /> Board of EclLialization(ROE)UST storage fee account number which is rcquircd br.'forc.y(fil-, N1111it application can Ill!,
<br /> Rc�,;Ntration with the 11011 will C11SUrC that you will receive a quarterly storage fee return in reporting,the S(W(K)(omill,)por gallon foo due;-1 the
<br /> numbcx of gallons placed in your USTS. 'llic 1101",will code persons exempt from paying the storage foe so rcwm� will not l)c nt, If you dr1 riot
<br /> have an atcouiunt nurnbci with 1110,1301i1f if YOU have any questions regarding the fee or ex0,rnptions,phrase call ilio B01;1 at 916 322'9669 or w6ic
<br /> to the BOE at.the follow ing addfcis Board of Equalization,Fucl Taxes Division,11,0,Box 94-18'79,Saciannento,(.'.A 9-4279 0001.
<br /> V. PFTI�of JUSl IUSTFINA\'CI At.,R ES 11ONSIB 1 LITY(MUST BE COMPLY 111)FOR 111'1 R011'L:M 1,,S Nl-�,SI:F,SIX*I IONS 2,-Il i)(
<br /> OFTITLE-23,CHAVITR 10,CALIFORNIA
<br /> Tdc.11tify rhc nicthoi(s)used by tine owner and/or operator,in mucting the Federal and State I[c,
<br /> any Fed-cral of st."[C,agcncy as%vctl as non pcLroleurn USTS are exempt from this requilcincl'it.
<br /> VI_LEGAL NO'I 111CATION A`\'D BILLING ADDRESS
<br /> clvvcK,ONI",BOX for t' address that will be used for BOTH I.EGAL AND Bll.-I,IN(.r NOTIFICATIONS.
<br /> TANK OW'NER OR AUTI 10RIZI.."D REPRESENTATIVS MI SI'SIGN AND DATE I'l IE FOR-NA AS INDICATED. [-,1 E SECI 10, 11
<br /> (a)(13)Ol,'I'll i,,E 23 CHAPTER 16,CAI.JFORNIA CODE 0! REGULATIONS]
<br /> INSIRUCIION POR HE LOCAI.AGENCIES
<br /> The county a1,,,jurisiticti oil nulyilx.rs are predetennified and can be obtained by calling the State Board(916)22"7-4303 Ilio facility nurnher may tx--
<br /> assigned by the local agency;however,this number must be numerical and carmot contain any alphabetical characters. If the local agency prefers
<br /> the State I.Ioarcf,to assign the facility number,please leave it blank.
<br /> 11' IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY Tlif, ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY IS REISPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY INFORMATION 13OX AND FOR
<br /> FORWARDING ONE' FOR.\l"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN TIIE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE-
<br /> RETALNE-)13Y TlIFiTANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723 FOR0120R1
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