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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL I STRLJCTIOItiS:
<br /> SECTION 2711 OF TI.1'LIi 23,CIIAPT•ER 16,CALIFORNIA CODE.OF REGULATIONS.AND SECTIONS.25286,25287,AND 25289 OF CHAPTER .
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERINUT 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 it the site.
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please iype or print clearly all requested information...
<br /> 5. Use a hard point writing instrument,you are making 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)(8),CCR].
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum US-T's(Section 2711(a)(11),CCR).
<br /> TOP OF FORM:"MARK ONLY ONE.ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITY/SITE INFORMATION&ADDRI SS(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.O.BOX NUMBERS ARE NOT ACCEPTABLE...
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSLNIiSSOW NERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,Check the box marked"YES".
<br /> & Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> I.I. 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 OWNERSIIIP'i'Yl'E box.
<br /> TIT.TANK OWNER INFORMATION&ADDRESS(,MUST BE COMPLE'T'ED)
<br /> Complete all items in this section,utiles all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OFEQUALIZATION US I ST'OItAUE FEE ACCOUNT NUMBER(,MUST BE COMPLETED.SEE-AIZ11CLE 5,CIIAIYT'ER 6.75,
<br /> DIVISION 20,CALIFORNIA 11E.AT.'TII AND SAFETY CODE.) i
<br /> Entcr your Board of Equalization(BOE)USI storage fee account number which is requirc&before your Permit application can be processed.
<br /> Registration%vith the BOE,wiii ensure that you will receive a quarterly storage fee return in reporting the S0.006(0mills)per gallon fee;dile on the
<br /> number of gallons placed in your USI s. The.I OE will code persons exempt from paying the storage fee so returns will no,be sea. If you do not
<br /> have an account number with the BOE or if you have any questions regarding the fee or exemptions,plcaso call the B01'at 916 3229669 orwrite
<br /> to the BOG at the Ibllowing address I3oard of Equalization,Fuel Taxes Division,11.0.13ox 942879,Sacramento,CA 94279-00;4.
<br /> V. PETROLLL I 11s FINANCIAL RESPONSIBILI'1Y(MUS,r BE COMPLIZ.TED FOR PIEDROI.EUM LIST'+ONLY,SFE SE.CI IONS 2711 (a)(S)
<br /> OF'ITTLE 23,CHAP TIiR 16,CALIFORNIA CODE'.OF REGULATION'S.)
<br /> Identify the mcdi(d(a)used by die owner and/or operator,in meetin the Federal and State firianci'A responsibility rcquiwnenl.s.USTs owned by
<br /> any Fedcral or State agency as well as non•petroleunt UST's are exempt front this rwuiremcnt.
<br /> VI.LECiALNOTIFICATION AND BILLING ADDRESS
<br /> Check ONE 1.3OX for the address that will be used for BOTH LEGAL AND BILLING LING NOT•1FIC1 IIO�\'-S•
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUSTSIGN AND DATE TITE FORM AS rNbICAT M, ]SEF S1 C T'1ONS 2711
<br /> (a)(13)OFTITLE 23 CIIAII ER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county an jurisdictic>n numbers are predetermined and can be obtained by calling the State Hoard(916)227-4:303. The f acuity number may ttc
<br /> assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local ager cy prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS TILE R11'.SPUNSIBII..TIY OF TILE LOCAL AGENCY THAT INSPECT'S THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, TI[IS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN: T11-$LOCAL.
<br /> AGENCY IS RESPONSIBLE FUR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR.
<br /> s FORWARDING ONE FORM"A"AND ASSOC.IAT'ED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RE'l•AI.N THF.ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY'l HETANK OWNER.
<br /> STATE OF CALIFORNIA :y 7YK-t'.""i Y-11 300
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527 t,:, V- b Y:r3
<br /> PARAMOUNT,CA 90723 a . ..,;,, --- .. .. �. .. .• �. �,. ,.
<br /> 393 4 ? ITv'.':^�;_=:tile"" ` q:5qV.. `fiTW; . YSQ3dhA1MO,a:1A.v tFJ-k ,
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