|
INSTRUCTIONS ST.. . gip FOR F "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 27111 OFINITLE 23,CHAPTER HEALTH
<br /> 16,CALIFORNIA CODE(7f Ind AUL ATIONS AND SECTIONS 25286,25297,Alii?25289 OF CHAPTER
<br /> 3
<br /> 6 ,DIVISION 2€I,CAI N ���
<br /> O
<br /> IA z1LTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> 1, One FORM"A"shall be completed for all NEWPERMIT CHANGES or any FACILITY/SFFE INFORMATION CHANGES.
<br /> 2. SUBMIT"ONLY ONE(l;FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This forma should be completed by esnhan—the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4Please type or print clearly all requested inforrmatiou.
<br /> 5. Use a heard p€lust writini,instrument,you are making 3 copies,
<br /> 6. Tank owner-must submit a facility p4ot plan:o ttae local agency as part of the applicaa€ion-shows ag the.kacation-opthe- S-Ts with respeetto
<br /> buildings and landmarks[Section 2711(a)(8),CCR].
<br /> 7. Tank owner must submit documentation showing eorr, hence with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(11),CCR]. -
<br /> TOP OF FORNtt:"MARK ONLY O3'db. ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is beim completed.
<br /> L FAC:ILITYISITF INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Rec6fil name add addrM. (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 naanae of the operator,
<br /> 2. Phone number must have an area code. 1f the nigdrt-.lmnabor is the saan'e,a ea "s., E"-in proper-location.
<br /> 3. Check the appropriate box fon-TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc,).
<br /> 4. Check the;appropriate.hoax fo T"�,"I OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservations or other Indian trust lands,check-the box marked"YES
<br /> 6. Indicate the NUMBER of TATS at this SITE.
<br /> 7. Record the E,P.A.IIS#or write"NONE"its the space provided.
<br /> IT. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLET EU)
<br /> Complete all items in this section,unless all items are tilt spm as SECTION 1,If the same,unite"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE bort.
<br /> III.TANK OWNER INFO tkIA ION&ADDRESS(vI S i BE COMPLETED),
<br /> Complete all items ins tln,a s{ son= � �e ss aL,d wu. a,re the same as SECTION 1;If the;sam ,vvriie.:aAKIE AS SITE Iw"jccoss tlaj, Qctietn_lie surd ,.a
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE AGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 2.0,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST storage fez:account number which is regiured before your permit applies€lora can be processed.
<br /> Registration with the SUE will ensure that you will ro ve a quapterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOF;will code persons exempt froam paying the storage fee so returns will imt-be-seru. If you-do not have ate- -- -
<br /> account number with the SOF or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> l3C)E a jhca clown,,g Iddress Boa d of Equaiizatiork,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001,
<br /> V. P TRO EL''M UST FINANCIAL RESPONSIBILITY(MUST BE Ct7? PUFFED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I I)
<br /> OF TITLE 23,CHAPTER 16, AL)FORN A CODE OF REGULATIONS.)
<br /> Identify the smed od(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility qui ments.USTs owned by
<br /> any Federal or State agency as well as non;-petrolcurn USTs are exempt front this requirement,
<br /> VI.LEGAL NOTIFICATION ANT)BILLING ADDRESS
<br /> Check ONE 11OX fter the addsea;s that will be aced for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK.OWNER OR AI;'T HOR Ii EST)REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER,16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county andjurkdiction nunnt e rs are pn cdetermined and can be obtained by calling the State Board(916)227-43€I3, The facility number may
<br /> be assigned by the local agency;however,this numbe,,r most be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State;Board to assip the facility mummer,please leave it blank.
<br /> IT IS THE n r ^ .p"r � .1–'1,' e w .S t :, m r. 17 v TO ?IEP II°Y,TI IE ACC,.1R ACY OF THE
<br /> ... ... ..:...r>�.,.. a.c.a .. .c,{3.., .W.,a... ..L'„< �a�.�, tx.ea _.. .x.. a ..,.
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS.RESPOINS,BLE, FOR THE; ieSslPLE IISNl OF`.IHE'aOCAL AGENCY IJSE QNLY” INFORMATION BOX, THE LOCAL
<br /> AGENCY SHOULD i`FL FAIN THE ORIGINAL ANIS ITTI.i..Cltav COPIES, THE PINK COPT'SHOULD BE RETAINED BY THE TANK
<br /> OWNER
<br /> 6195
<br />
|