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INSTRU*IONS FOR COMPLETING 14�M "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE,23,CHAYFF.R.16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTI I AND SAFETY CODE'REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/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 past of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner mut submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs lSeciion 2711(a)(11),CCR].
<br /> TOP OF FORM:"MARK ONLY ONE ITE''I"
<br /> Mark an(X)in the box next to the itern that best describes the reason the form is being completed.
<br /> I. FACILITY/SLIT 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 /> P.O.13OX 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 TYPE OF BUS INE'SS DNVNERSH IP(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'I'ANKS at this SITE.
<br /> 7. Record the E.P.A.ID it or write"NONE"in the space provided.
<br /> I.I. IIROPI-'I2'['YOW.Nf-',RL'\'I,'ORMA'l"lON&ADDRESS(MUST BI.-COMPLETED)
<br /> Complete all items in this section,uriless all items are the same as SEC710N 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> IIL TANK OWNER INFORMA110N&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1:If the sante,write'*SA.',Ir AS SITE"across this Section- Be sure
<br /> to check"TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION US I'S'10RAGE FE11'ACCOUNT NUMBER(MUST13F.CONIPLETE.D.SFE AR'rICI,E 5,CIIAI-f'[,'R 6,75,
<br /> DIVISION 20,CALIFORNIA IIIIAL'I'll AND SAI,-I.,.TY COIN.,-)
<br /> Enter your Board of Equalization MOE)UST storage fee account number which is required bc4ore,your permit application can tic processed.
<br /> Rcz; tration with the 1306 will C11sule that VOLI will receive.a quarterly storage fee rcium in reporting the$0.0()6(enrolls)per gallon fee due on the
<br /> nurnl%ei of gAlons pl.i,:cki in your US'ls. 'Ilse BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not
<br /> have an account number with the BOE or if you have any questions regarding the tee or cxcriiptions,Please call the BOE at,916-3112 960)or write
<br /> to the 1301.,at,the following addrcss Board of Equalization,Fuel'faxes Division,P.O.Box 9,11221579,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM LSI'FINANCIAL.Rl.,'SPONS1131111'Y(MUST'BE COMPLETED FOR PIIJ R01.1"UM USIs ONLY,SIT'.SE(A 1021"S 2711 (a)is)
<br /> Of.11,111-l'23,Cf IAVFER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used bythe owner and/or operator,in meeting the Federal and State [cq)on,ibi1iiy iuquirenicrus, LISTs owned by
<br /> any Federal or State agency as well as non-petroleurn US'I's are exempt from this requirement.
<br /> VI.LEGAL N01 IHICATION AND BILLING ADDRESS
<br /> Check ONEBOX for the,address that will be used for BOTH LEGAL AND BILLING NO'I'll"ICATIONS.
<br /> TANK OWNER OR AU'I'liORIZED REPRESENTATIVENIT SI'SIGN AND DA'I'S THE.FORVIAS INDICA'I'FI). jS1:i:.sl-.criom 2711
<br /> (a)(13)OFTITLE,23 CHAPTER 16,CALIFORNIA CODE Or:REGULATIONS.]
<br /> J
<br /> INS'IRU(7l'ION FOR TI fE LOCAL AGENCIES
<br /> The county an jurisdiction it'umbers are predetennined and can be obtained by calling the State Board(916)227-4303. 'Ibe facility number may be
<br /> assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> 11'IS THL'RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY I'llE ACCURACY OF THE
<br /> INFORMA11ON. THIS APPIJCATIOIN CANNOT BE PROCESSED IF THE BOE ACCOUNT NU.MBIA IS NOT FILLED IN. T'H'E FOCAL
<br /> AGENCY IS RI.-,SI'Oi\SlBl-E FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FOP.M"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN'FIll--'ORX;1NALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS,THE PINK COPY SHOULD BE
<br /> RETAINED BY TlIE.TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3,193 FOWWRI
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