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s ,� ' INSTRU(*ONS FOR COMPLETING F "A" y GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CIIAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITYISITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(I)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site. 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. S. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to buildings and landmarks(Section 2711 (a)(8),CCR]. 7. Tank owner mint submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the . application for petroleum USTs[Section 2711(a)(11),CCR]. ' i TOL'OF FORM:"MARK ONLY ONE ITENI" Mark an(X)in the box next to the item that best describes the reason the form is being completed I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) 1. Record name and address(physical.location)of the underground tank(s). NO'T'E: Address MUST have a valid physical location including city,state,and zip code. P.O.BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number roust have an area code. If the night number is the same,write"SAME"in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERS141P(ex.CORPORATION,INDIVIDUAL,etc.). 4. Check the appropriate box for TYPE;OF BUSINESS. 5, If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES". 6. Indicate the NUMBER of"TANKS at this SITE. 7. Record the E.P.A.ID#or write"NONE"in the space provided. Il. PROPERTY OWNER INl-'ORMATION&ADDRESS(MUST BE;COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. .Ill.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPI.ET'ED) l Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SANTE AS SITE"across this section. Be sure to chcck,rANK OWNERS TYPE box. IV.BOARD OF EQUAI1ZA'l`lON USTSTORAGE~FEE ACCOUNT NUMBER(MUSTBE CONIPLE"IT.D.SEE AR ICLE 5,CILAVIT'R 6.75, DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.) I:int.er your Board of Equalization(13017)UST storage fee account number which is rcquircd lx--fore your permit applicaflon can be processed. Rei;:stratton with the BOh will ensure that you will receive a quarterly storage fee rctum inreportingthe$0.Utt6(innil.ls)per gallon fee clue on the ntnnber of gallons pl:a,cd in your USTs.Ts. •I}te BOT:;will code persons exempt from paying the storage fee so returns will not be sant. If you do not have an account itttmber widt 111.1301.:or if you have any questions regarding die ice or c Xernpt.ions,please call the 110L at 916-3.12-9669 or write to the 1301.1 at.doe following address 119ard of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94279-0001. V. I'L'TROLL•L1\1 L'Sr FL1ANC:IAL RESPONSIBILITY(`LUST BE COMPLETED FOR PEI ROLEUM USTs ONLY,S[El.SEcl1ONS 2711(a)(8) l OF TITLE 23,CII,APTER 16,CALIFORNIA CODE OF REGULAT'IONS.) Identify the methods)used by the owner and/or operator,in meeting the Federal and State financial resporisibility'requirements LTS71's owned by any Federal or State agency as well as non-petroleum.USTs are exempt from this requirement. VI.LEGAL.NOTIFICATION AND BILI.,ING ALORESS Check O:NEi 13OX for the address that will be used for BOTH LEGAL AND BILLING;NOTIFICATIONS. TANK OWNER OR AUTHORIZED REPRESENTATIVE MI STSIGN AND DATE THE FOR.XI4 AS INDICATED. [SEti St..-nom 2711 (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE O-T,REGULATIONS.] INSTRUCTION FOR THE LOCAL AG'ENC'IES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916Y217-4303. At facility number maybe assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS THE RESPONSIBILITY OF THE I.,OCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS,THE PINK.COPY SHOULD BE ` RETAINED BY THE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.EX.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 3193 F=120M f;