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INSTRUCTIONS FOR COMPLETING FORM ItAil
<br /> GEINERAL INSTRUCTIONS:
<br /> SFC`I'JON 2711 OF TITLE 23,CFlAPTrR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.4,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PER-MIT.
<br /> 1. One FORM"A"shall be completed for all,N LW PERMIT CHANGES or any!-ACII—Ti 'N FORK]ATIONCIIANGFS,
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facdity/SitL,regardless of the nurrber of tanks locaced at the site.
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSP 7
<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 part 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 must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(11),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITENI"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> L 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.BOX NUMBERS ARF NOT ACCEIYFABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 1 Phone number must.have an area code. If the night number is the same,write"SANTE"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc,).
<br /> 4. Check the appropriate box forTYPE OF WJSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation Or other Indian tnist lands,check the box marked 1. 'YE
<br /> S".
<br /> 6, indicate the NUMBER of TANKS at this SITE.
<br /> 7.. Record the E.P.A.ID 4 or write"NONE"in the space provided.
<br /> IT. PROPERTY OWNER IN FORMA TION&ADDRESS('MUST 13 E COMPI.LTFD)
<br /> Complete all items in this section,unless all items are the sante as SECTION 1,If the same,write-SANIE.AS SITE"across this section. Be sure
<br /> to check PROPERTY OWN ERSHIPTYPE box.
<br /> III,TANK OWNER INFORMATION&ADDREISS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;if the carne,write"SAME AS SITE"across this section, Be sure
<br /> to check TANK OWNERSTY11L box.
<br /> IV.BOARD OF EQt UST STORAGE FEE ACCOUNT NUMBER(MUST'BE COMPLETED.SEE ARTICLE 5,CHAP '1 6.75-1
<br /> DIVISION 20,CALIFORNIA lll:ALTJI AND SAFETY CODE,)
<br /> Enter your Board of F"quidlization(BOIL)GST storagv fee account number which is required before your permit application can be.procvswd,
<br /> Registration with the BOL will cusuic that you will receive a quarterly storage fee rculnl ill reporting the$0.006(6milk)per gallon fP,,(,,duo on the
<br /> nurnber of gallons placed in your USTs. The BOE will code parsons exempt from Paying the storage fee so returns will riot be q"rz. If You do not
<br /> have an account number with the,13OF Or if you have any questions regarding the fee Or CXC1nP1i01)S,,-d(;ASc Call the 23011 3t 9 Tri.'122-966")or wri!o
<br /> to the BOF:at the following adiiess Hoard of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94271)OC`)l
<br /> V. PE FROLEUM"'S FFINA' CJAI,RESPONSIMITI Y(MUST BE COMPLFTLD FOR PETROI-ET—M":,S I's ONLY,Shk SEIC'l I
<br /> OF TITLE 23,C1 IAPTER 16,CAI,lFORMA CODE 01;Rc-1(3iU1,ATION&)
<br /> Iduri- the Tric i hod(s)used by the owner and/or operator,in nicer ing the Fede K a!and State"i n,:n c i al rc.sp,)r i s i b ih t y req;i i t,c n,c,,ru 1.41 S v,rtcaI by
<br /> any Federal Or Suite agency as well as non-petrolcurn US"I'i are exempt from this re/quiicrncllt.
<br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE:BOX for the address that will be used for BOTH LEGAL AND 131I.I.LNGNO I'll-ICATIONS,
<br /> TANK OWNER OR.AUTHORIZED REPRESENTATIVE MUST SIGN AND DATETHE FORNI AS INDICA'l ED. [SIT SD, "TONS 2711
<br /> 16,CAI.JI;ORN'IACODE OFRI'(,LrLA'11(.)�S.I
<br /> INSTRUCTION FOR THE'LOCAL AGENCIES
<br /> The county an jurisdiction nuinlx:rs are predetermined and can be obtained by calling the State Board(916)227-4303. The facility nornberni'ay be
<br /> assigned by the local agency'however,this 11111TA)er 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 /> IT IS THE RE'SlION'SIBILITY OF THE LOCAL AGENCY TIIAT INSPECTS THE FACILITY To VERIFY THE ACCURACY OF'IJIE,
<br /> IINFORMATION, 'I HIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. 11-4E LOCAL
<br /> AGENCY [S RESPONSIBLE FOR THE COMPLETION OF rHE **LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE DORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOATNG ADDRESS. TIIE LOCAL AGENCY SHOULD
<br /> RETAIN THE.'ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINEID BY'l IIETANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.13OX 527
<br /> PARAMOUNT,CA 90723
<br /> 3 93 FOR012DR1
<br />
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