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INSTRUCTIONS FE "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITT.E 23,CHA ITER 16,CALIFORNIACODE ODE OF REGULATIONS AND SECTIONS 25286,25287,AND 2528§'OF CHAPTER
<br /> (5.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING I ERNIIT,
<br /> 1, One FORM"A"shall be completed for all;NEW PERMIT CHANCES or any FACILITYISITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(l)FOR: "A"for a Facility Site,regardless of the number of tanks located at the site.
<br /> 3. This foram should be completed by,either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR;
<br /> 4. Please type or pont clearly all requested information.
<br /> 5. Use a bard paint writing instr went,you are nsa"king 3copies,
<br /> 6. Tank owner must submit a Facility plea plan to the locum agency as part sof the application showing the lobation of the USTs with respect to
<br /> buildings and landmarks[Section 2713 (a)(8),CCR),
<br /> 7. Tank owner ataust submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application far petroleum LSTs BIe tion 2711(a)(1I),CCFZ).
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark-an IX)in the box next to the"stern that best describes the reason the form is being completed,
<br /> 1. FACILITYISiT-ST INFOR\4A rION&ADDRESS FSS(MU ST BE Cf;M1'LETED)
<br /> f. Record name and address(physical location)of the underground=,ank(s).
<br /> NOTE: Address MOST have a valid physical location including city,state,and zip code.
<br /> RO,BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cress stmt goad name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write;"SAME„inTroper location. _
<br /> 3. Check the appropriate box forTYPE OF BUSINESS OWNERSHIP{ex.CORPORATION,INDIVIDUAL-,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS,
<br /> 5. If FacilitylSitc is located within an Indian reservation or other,Indian truat'lands,check tiv�bot marked`"YES„
<br /> 6, Indicate the NUMBER BER of rANKS at this SITE.
<br /> 7. Record the E.P.A.ID q ar write"NOI.D"in thespace presided,
<br /> 11. PROPERTY OWNER IN-FOC RMA t ION€e ADDRESS(MUST a B C EThTtPLE%ED)
<br /> Complete all stets:n this sectio,,,unless all items are the saris e a.SECTION ION I;If the sasne,write"SAME AS SITE"across this srationt e sure
<br /> to check PROPER'%'Y C)VITvF'RSHIP TYPE box,
<br /> 111.TANK OWNER INFORMATION r rM.)13.,..,1 S(SIDS f TIC
<br /> Complete all lairs in this s:_,rc tt ['talcs all s€-tits pry ffic s mc,as SECTION 2Nd t,If the carne,write";AME AS SITE"across this section. Be sore
<br /> to checkTANK OWNERS,F'NERS 1"YPE box.
<br /> IV.BOARD OFEQUALIZATION LST STORAGE E FEE ACCOUNT NUMBER(MUST BE COMPLETED,SEE ARTICLE 5,CHAPTER 5.75,
<br /> DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)LISTstorage fee account number which is required before your permit application can be processed.
<br /> Rc.-istration-t da the SU will ensure that you will roe eive ea quarterly st�ara�fee return in reporting the per gallon fee due on the number of
<br /> gallons placed;n your USTs. t"Pr UE will code pe so s exemp€frons pang die storage fee so returns will not be sent. If yoga do not have an
<br /> acco€int moulrer with the BOE or its gulf ba, a,y qui tions,,,e ,�i_nt=the fuss or exemptions,please call the BCF:at 916-322-9669 or write to the
<br /> BOE atthe following address Board Fuel Taxes Division,P.O.Box 9,12879,Sacramento.CA 942.79-0001,
<br /> V. PETROLEUM UST FINANCIAL RES N alsaiLITY yMU'ST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (1)(11)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CC'?:)In OF REGULATIONS.)
<br /> Identify the mathod(s)used by the owner andloc operator,im z.seting the Federal and State financial responsibility requirements,USTs owned by
<br /> any Federal or State age rs y as well as non pearolev>um USTs a c exernpt from this requirement,
<br /> V1.LEGAL NOTIFICATION AND tali a sC ADDR a,S:
<br /> Check ONE BOX for the address that will>sc used par 130111 LEGAL,AND BILLING NOTIFICATIONS.
<br /> TALK OWNER OR AUTHORIZED R PRESF.,",'I"A b IVE N1t 1S'I'S GN AND TATE THE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(]3)OF TITLE E 22 CHAT'FER 16,CALIFORNIA NIA CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> NC IES .
<br /> The county and Jus :,diction numbers are pt Wsetermsn,d ansa=can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigned by the log gala ,cncy;h,w evcr,this rtunate r[trust be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to .",ge the facility numlxes' of ase leave it blank.
<br /> IT 1S THE RI.SP I,NSIBaa_?r t.. '11,1111E, x. , .,,,z Y ,„,a ,. 3 ,B ITT b e vC ILI Fra'TO VERIFY TIM ACCURACY OFTHE
<br /> INFORMATION, THIS APPLICA E IONI CANN£T1 BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY .;S RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORmATION7 BOX, °T14E LOCAL
<br /> AGENCY `a"i-1iHULD TTI: ATN"IHE ORIGINAL AND YF.1..1.OW COPE`. THE 'rI`KCOP'Y STIOPTLD BE RETAINED BY THE TANK
<br /> OWNER.
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