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INSTRUCTIONS FOR COMPLETING FORINI 11VIV
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 271 l OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS ANT)SECTIONS 25286.25247,ANIS 25289 OF CHAPTER
<br /> 6-,7„DIVISION 20,CALIFORNIA HEALTH AND SAFETY COBE REQUIRE t?trdNERS TO APPLY FOR AN UST OPERATING E PREM".
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANCES.
<br /> 2, SUBMIT ONLY ONE(I)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 UNDERGROUNDTANK INSPECTOR,
<br /> 4: Plepse type or print clearly all requested information,
<br /> S. Use a hard point writing instrument,you are making 3 copies,
<br /> . Tank owner must sulin.t a facility plot plan to the local ageircy its pay of the application slidwing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711 (aa)(9),CCR).
<br /> 7, Tank owner must submit documentation showing compliance with state financial responsibility m lu:rcruents to the local agency as part of the
<br /> application for petroleum US-Ts[Section 2711(a)(1 1),CCRJ)
<br /> TOP OF FORM."MARK ONLY ONE ITEM"
<br /> Mark air(k)in the box next to the item that best describes the reason the form is beam completed,
<br /> 1. FACILITY/SITE INFORMATION&Ai KESS(,MUST BE CG1MPLE"zE'Z?)
<br /> I. Record name and address(physical lc,66 0 of the underground tar,k(s).
<br /> SHOTE: Address MUS-;T have a valid physical locationn including city,state.,and rip cry=1e,
<br /> PCO.BOX NUMBERS ARE NOT ACCEPTABLE,
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<br /> Include-nearest cross street and name the operator.
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<br /> --2. Phone-number mast have an area code; If the night nurnber is thesmnc write"SAME"in pTrt per to 2das;.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,eta,.), W,
<br /> 4, Check the appropriate box for"T`i E OF BUSINESS,
<br /> 5. If Facility/Site is l Hca€ed within an Indian reservation or b(her'indian trust lands,check.the bryx i arke 1 YES",
<br /> 6, Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E:P.A_ID#or write"NONE"in the space provided,
<br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> _v Complete all items in this section,unless all items are the same as.SECTION t;if the same,write"SAME AS SITE"across this section. Be scare
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III,TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the saanne as SECTION I;Ifthe same,write"SAME AS SITE"across this section. Be snare
<br /> to check TANK OWNERS TYPE.box,
<br /> IV,BOARD OF EQUALIZATION LIZA'TION US`I STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED,SFE ARTICLE 5,CHAPTER 5.75,
<br /> DIVISION 20,CALIFORNIA HEALT'I-I AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)'UST storage fee account number which is required before your pertaait application can be processed,
<br /> Registration with the 130E will ensure that you will receive a quarterly storage fee return in reporting the per gallop fee due on the number of
<br /> gallons placed in your USTs. The BOE will code personas exempt from paying the storage fee so returns will not he sent. If you do not have an
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 9I6-322-9669 or write to the
<br /> BOBat the Following address Board of Equalization,Fuel Taxes Division,P.O.Box 942479,Sacramento,CA 94279-0001,
<br /> Y. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (n)(I 1)
<br /> OF TITLE 23,CI1 APT-ER 15,CALIFORNIA CODE OF REC;I_)LATIONS.)
<br /> Identify the method(s)rased 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-petrolcum USTs are exempt from this reeluircrnemt
<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 AUTHOR17ED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION 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 loaaFagency;however,this number must he numerical and cannot contain any alphabetical character,. If the local apncy
<br /> prefers the State Board to assign the facility number,please leave it blapk,
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL.AGENCY THAT INSPECTS THE FACILITYTO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE ROE ACCOUNT NUMBER IS NOT TILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOK, THE LOCAL
<br /> AGENCY SHOULD RE'I"AIN THE,ORIGINAL ANY YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE:TANK
<br /> OWNER,
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