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INSTRPIONS FOR COMPLETING AM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTIO 2711 O1 TlTLl,23,C HAi'IER 16,CALIFORNIA CODE,OF REGULATION'S A-IND ECTIONS 25286,252 7,AND 25289 OF CHAPTER}
<br /> 6.7,DIVISION 20,CALIFORNIIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> I. One FORM"A"shall be consplcted for all N LW PERMIT T CHANGES or any FAcILmIsm INFORMATION CH ANGE&
<br /> 2, S1.I3a`w IT ONLY ON (1)I'C3l2.M"A"for a Fac ity�7Site',regardless of the number of tanks located at the site.
<br /> 3. This form shoutc3 be conipleted by either the PERMIT APPLICANT-ot the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use>ahard point writing instrument,you are making 3 copies.
<br /> b. Tank owner must submit.a-facility plat plats to the local agency as part of the application showing the location of the C.ISTs with respect to
<br /> buildings and landmarks[Section 2711 (a)('8),CCRJ.
<br /> 7i Tank owner must submit documentation showingc€midiance with stare financial responsibility requirements to the 1a>a<alagency as part ofthe
<br /> application for petroleum USTs(Section 2711(a)(t 1),CCR).
<br /> TOP OF FO NC"MARL(ONLY ON1.11"p1t"
<br /> -Marl:an(X)in the box next to the item that beret desc'riltc s the reason the fortta is being Complete&
<br /> I. FACILITYISITE INFORM ATION:&ADDRESS(MUS'1"BE COMPLE11,D)
<br /> L Record name and address(ftbysical:location)of the underground tank(s).
<br /> NOTE:Address LST have a valid physical Iocaeion including city,stale,and xilscode
<br /> P.OBOX CUMBERS ARE;4iOT ACCI?,lw'S'ABLE.
<br /> Include nearest cress streetand name of the operwor.
<br /> 2. Phone number must have an area code. if the night numflxr is the same,writs;"SASE"itl proper location.
<br /> 3. Check the afpropriaw ixax for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for`I YPE OF 13L KNESS,
<br /> S, If-Faediiy/Site is located within an Indian rescrw%adon or other Indian trust lands;check the box masked"YIiS".
<br /> b. Indicate the NUMBER BER of T"A.NKS at Leis SITE;,
<br /> 7...Record.the E,RA,11).#or write NONE"in tine space provided.
<br /> It. PROPERTY OWNER INFORMATION&ADDRESS{141TS '}3I COMPL,E-11-M)
<br /> Complete;all items in this secrtiou,usa;ess all items are the sarne as SEC.'l'ION I;If the same,sarins"SAMF AS SITE"across this section, Be scare
<br /> to check PROPERTY OWNERSillP TYP box.
<br /> 111."I'ANK OWNER IN1't RNIA`I"ION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all iterns'in this section,unless all items are the sarne as SEC I ION 1;If tate sante,write".SAME A,&SITF."acrou, Lhis scelio t. Ile guns
<br /> to checkTANK OWNE€ S T YIT,box.
<br /> IV,BOARD OFEQUALIZATION UY'ST STORAGE F-E ACCOUNT:til BE-R(NIUST BE C ONII'1.I;`ED.Slip:ARTIC' 1,5,CHAVI ER ta35,
<br /> DTVI"SiON 20,CALLFOIt` I A I1L Al:I'll AND S.At,'-,- 1`C( D? )
<br /> tinter yout Board of Male alap,acn I3f)1:3:U 1 storage fee account nurnb€:r which is requited twfore your pare tt application ation c.an he proccs.ed.
<br /> RCg istration_tw"ith 1110 IlOE will ensurc that w sat will receive a quarterly sxrtage fee return in repotting are$0,W6(6mil )1xr gallon tee drat on the �
<br /> to tralaer of gallc.r.s Iatac .d sr.your US I's. "l iaa:a3f ll uilhcoue Ix rsatts exersapt fr<afta pavint,tltc storage fee sea r ttaxsi,w Il r ct 1> , ttt. 1L xxu do n<st
<br /> have,ata account uuttabc.r with the BOF or if you have any questions regarding the fee or excmptions,�plc ase call the II01",tit llfi 322 0069„r write
<br /> to the 1301:at tate f allo"s ing addicss Board of F"qualizatiun,Nuel Taxes Division,P.O.Bon 942879,Saac"rtzt icnio,(`A`9 22 7Q-0001.
<br /> V. 111;'i1 OL1,t M,US i'1I1NANC IALa RESPONSIBILITY(Ml_;'S'F Bf,'COMPL1:"1'1:1` FOR 113"F OLE"UA1 USTs ONLY,SEE SEC11ONS 2111 (a)(S)
<br /> OFTITLE 1.E 23,C11r51'°1'IiR 16,CALIFORNIA COD1'OF RlX3u1.ATIONS.)
<br /> IdCn1,l v tree tzic thkxl(�,)uscd.by ihe..owner andq'>r opa,;a or,a.a meetisig the Fed-,ral and State financial reslavttcibilii L 5.1. e wn. 4 say
<br /> any 1 edct rl o? State agst nc:y as well as nota pctrcile.,u i U's I's pan;excrnpt frorn this tequarcrnctn.
<br /> d
<br /> Y1.Ll.€tlA1.'OTI IC ATIO'w AND'WILLING ADI)101,,S
<br /> Check,ONE:BOX for de.,a''dr ss ihLl w.;11.,c uF od fm 130 I'll LEGAI,A,4T7 BI1 LING a`r(YFIFIC Al IONS,
<br /> TANK O1A''NEK 0IR AtJTI l{)ialZF',D AND DATE"HE'FORM A4 INDICATED.ED. (. ,.3.'tirC I'Iti`S 2711
<br /> {a)(I3)C3z''l f I'l.ti'>:L IIAE'1'r= 16,CALIFORNIA CODE OF REGULATIONS.1
<br /> INIS'I 21 C1`ION FOiC'hH LOC'.AL.AC ENCIEs
<br /> The county an jurisdici ion numbers are prc:dc;ttrn'nine and can be obtained by Galling the State;13oard(916)227 4301 (hc. ,aci.t.y number rt,ay I>C
<br /> assigned by`ttae local agency-,bowwever;this nwnb a ntuat be numerical and cannot contain any alphabetical If the lo(,al agency prefers
<br /> the State:11ct:atd to assign the facility number,please leave it blank.
<br /> ITIS TIll; RESPONSIBILITY OF THE' LOCAL AGENCY ISP C IS THE FAC.'I1.ITY 10 VERIFY`MITI:ACCURACY OF THE
<br /> I:v}rO MAT ION. TI IIS APPLICATION ION CANNO f"BE PROCESSED IF THE 130E AC.COUN NU BER IS' O`t 11ILl,LrI)IN, THE 1.()CAL
<br /> AGENCY IS RESPONSIBLE FOR THE C.`0,\-IlaLFJION OF THE "LOCAL AGENCY USE C3itiLY" INFORMATION BOXANDFOR
<br /> FORWARDING*ONE,FORM":A"AND ASSOCIATED FORM"B"(s)TO THE 1.OLL:>C)`h"1.NC1 ADDRESS, THE LOCAL AGENCY SfIOULI)
<br /> RETAIL 11111;O IGENAA S AND FORWARDTHE I"IF YE:LI.OW COPIES TO THE FOLLOWING ADDRESS,THE"PINK COPY SHOULD BE
<br /> RETAINED BY]HE' TANK OWNER.
<br /> S'AT'E OF CALIFORNIA
<br /> STATL WA`T`ER RESOURCES CONTROL BOARD
<br /> CIO S.Lae.E,E.P.S,
<br /> DATA PROC:ESSDiG CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3�3 F 120R1
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