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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25256,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEAL`I"I-I AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<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. Please type or print clearly all requested infortr€ation.
<br /> 5, Use a hard pointritin instrument,you pare maiming 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)(S),CCR].
<br /> 7,'Tank'owner must sTabr6it documentation showing do`mplia nce with°state financial responsibility requirements to the Racal agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(I1),CCRJl
<br /> TOP OF FORM "MARK ONLY ONE EM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> T. FACILITYISITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1, 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.OBOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Rhone number must have aro area co4e. if the night number is the same,write"SAFE"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. i . . .
<br /> 5.,If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES°'.
<br /> 6.Indicate-the NUMBER of TANKS at this SITE,, d
<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 /> Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE,"across this section, Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) t,`
<br /> Complete all items in this section,unless all items are the same a SECTION 1;If the same,write"SAM AS SITt across this section. Be sure
<br /> to check TANK OWNERS TYPE box,
<br /> IV.BOARD€3F EQUALIZATION LIST 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"storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure.that you will rcceiyt,a quarterly storage fee return in reporting the per gallons fee'due o the number of
<br /> gallons placed in your USTs. The 1303E 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 regardin.the fee or exemptions,please call the BOB at 916-322-9669 or write to the
<br /> BOB at the following address Board of Equalization,Friel"taxes Division,P.O.Box 942579,Sacramento,C.A 94279-0001, •
<br /> V, ETT OLEIJM-UST"FINANCIAL RESPONSIBILITY(MUST BF C O PLETED FOR PETROLEUM(.;STs ONLY,SEE SECTIONS 2712`'(a)(I1)
<br /> OF TITLE 23,CII:APTER 16,CALIFORNIACODE OF REGULATIONS.}
<br /> Identify the method(s)used by the owner and/or operator,in rnee€in;the Federal and State financial responsibility requirements.UST's owned by
<br /> any Federal or State agency as well is non-petroleum USTs are exempt from this requirement.
<br /> VL 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 AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED, (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE€3F REGULATIONS.]
<br /> INSTRUCTION FOR TIME LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Hoard(916)227-4303, The facility number may
<br /> be assigned by the local agency,however.this number must 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 BOE ACCOUNT IS NOT FILLED IN, THE LOCAL.
<br /> AGENCY IS RESPONSIBLE FOR TIME COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL ANIS YELLOW COPIES. TIME PINK COPY`SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
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