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INSTRUCTIONS FOR COMPLETING FORM "At'
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIrORNIA CODE OF REGULATIONS AND SECTIONS 15286,25267,AND 25259 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH 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(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the sista,
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL L AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or plant clearly all requested infopraation.,
<br /> 5. Use'a.h tr.point wr ting'insussit nt,, ou acre mpk-ung 3 c€oics. :a
<br /> 6. Tank owner must submit a facility plot plan to the l6cal agency as part of the applicatio3l'showin the location of the UST,with r€:slaect tcx
<br /> buildings and landmarks[Section 2711(a)(S),CCR].
<br /> 7. Tank owner must submit d icu€taemation showing compliance with state financial responsibility requirerrtenut to the local agency'as part of the: ,
<br /> application for petroleum US"Ts[Section 271 I(a)(l t),CCR].
<br /> T'C3O]F FORM:"MARK ONLY ONE ITEM°' • � 1 '. ,
<br /> Mark an(X)in the box next to the item that best describes the reason the form is beim completed.
<br /> I, FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tanks).
<br /> •INCITE: Address MUST have a valid physical location including city,state,and zip code, b
<br /> P.O.BOk UMBERS ARE OT ACCEPTABLE,
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number trust have an area code. If the might number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box.for TYPE OF BUSINESS OWNERSHIP(ex.CPRPORATIC? INDIVIDUAL.,etc.).
<br /> 4. Chief the appropriatebo€fo€ATYP'E F 51NESS.
<br /> 5, If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES",
<br /> 6. Indicate tris«NUMBER,of TAN KS at tuts SIfE,
<br /> 7, kecord the E.P.A.IL? or write>,NC)N'E' in tbe space icsvlded.
<br /> 11. PROPERTY OWNER INFORMATION I&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items tine the same as SECTION 1;If the same,write."SAME AS SITE"across this section, I3e•sure ,
<br /> to check PROPERTY OWNERSHIP HIP TYKE box. '
<br /> III.TANK 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 SITU'acibss this Sectio114 Be sure �
<br /> to check TANK OWNERS'TYPE box,
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<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE X RTI L.E 5,4ffkAPTEI,6.75, ?
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your I3oard,of Equalization(BOE)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration withst e B-O *iWerearre that yo4 will receivt 4,quarterly stomgq fee retum,in reporting the per gallon fee due 9n the numbef of: .
<br /> gallons placed in your I>rS'I s.
<br /> Thc'b6E will c ode'pers6ns ixempt from aying the ktara e fee so tufass will not be"96t. if you zIa'noY fi tvars
<br /> account number with the BOE or if yon have any questions regarding the fee or exemptions,please call the BOE at 9J6-3
<br /> 22-9669 or write to the
<br /> BOE at the following address hoard of Equalization,Fuel Taxes Division,P,O.Box 942879,Sacramento,CA,94279-E1I#Cll,
<br /> . R LF4Rv1:CST.FINANCIAL RES PONSI13ILITY:(MUST Rg,COMPLETED FOR PETROLEUM USTs C}l*Ky--;.SEE SECTIONS 2711(a)(11)_
<br /> OF TITLE 23,cIIA7'TER'16,CALIFORNIA Cc�1� cap RECIULA°ric�NS.}
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<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well las non-petroleum USTs are exempt from this requirement,
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<br /> 'tri.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL,ANIS BILLING(NOTIFICATIONS.
<br /> TAMC OWNER OR AUTHORIZED REPRESENTATIVE MOIST 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 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 BOB ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL.
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORMATION BOX. TIME LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES, T COPY OPY SHOULD BE RETAINED BYTHE TANK
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