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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23.CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,QIVISION 20,CALIFORNIA HEALTH 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 INF'ORMA'TION 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 APPLIC:ANT,br the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> d. Please type or print Cllearfy all requested information. _
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 6, Tank owner roust submit a facility plot plan to the local agencyas part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR]:'
<br /> __7. Wank owner must submit documentation'showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> appl€cation for petroleum;LISTS[Section 2711(a)(I1),CCR].
<br /> TOP OF FORM:".MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITYISITE INFORMATION&ADDRESS(MUST BE COMPLETER)
<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 ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and narne 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 BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands,check tlhe'box marked"YtS"
<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 /> IL PROPERTY OWNER INFORMATION&ADDRESS(MUST BE-COMPLETED) _
<br /> Complete all items in this section,unless all'itenzs:are the same as"SECTION 1;If the same,write„SAME AS SITE"across this section. Be snare
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> til.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all i€encs in,this section,unless all items arc the same as SECTION i;If the,sante,write."SAME AS SITE"across this section,,.Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)UST„,5torage fee account number which is requice`cl before your perrnit applis;ation'can Ve processed. -
<br /> Registration with the BOE will ensure that you W ill receive a quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your LSTs. The BOE will code persons exempt from paying the storage fee so returns will not be 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 916-322-4669 or write to the
<br /> RQE at the ollowing address Board of Equalization,Fuel Taxes Division.P.O.Box 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711(a)(I1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibilit requirements,USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE 13EOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATI€ONS.]
<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 local agency;however,this number trust be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number;please leave it blank:
<br /> IT IS THE RESPONSIBILITY`(OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE 130E ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL.
<br /> ,AGENCY IS SPON II3LE F(31Z THE COMPLETION OFYIJOCAL..AQ !qG _US- 4O�NLY" INFORMATION BOX. THE LOCAL
<br /> U_ �
<br /> AGENCY SHOULD RETAIN THE ORIGINAL,AND YELLOW COPIES. THE PINK COPY SI-&LII BE RETAINED BY THE TANK:
<br /> ., OWNER. ..::,.. ,.-... - . .,, :.. .... :-.
<br /> 6195
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