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INSTRAIONS FOR COMPLETING *M "Att
<br /> GENERAL INSTRUCTIONS:
<br /> SIECITON 2711 OI' ITFLE 23,CHAPTER 16,CALIFOR IA.COBE OF REGULATIONS AND SECTIONS,25286,25287,AND 25289 OF CIIAP'I1R
<br /> 6:7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN USTOPERATING PERMIT".
<br /> 1. One FORM"A"shall be completed for all NEW PERMf'J;CIIANNGES 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 site.
<br /> 3. This form should be completed by either the PEIL4IIT APPLICAINT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4, Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are[Waking 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 USI's with respect to
<br /> buildings and landmarks[Section 2711 (a)(S),CCRI.
<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�USTs[Section 2711(a)(11),CCRI.
<br /> TOP OF FORM:'.'MARK ONLY ONE I'M%yl"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FAC'ILd'1'Y/SITE.INl'Ol2MATION&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.O.BOX NUMBERS ARE NOT ACCIEP'FABLE.
<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 BUSINESS OWNERSHIP(ex.CORPORATION,IIN'DIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINLES&
<br /> 5. If Facility/Site is located within an Indian resen ation or other Indian trust lands,check the box[narked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE,
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> H. 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 sectio n. Be sure
<br /> to check PROPERTY OWtiERSI III'TYPE box,
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST IIF COMPLETED)
<br /> Complete all items in this section,unless a1.1,items are die same as SECIION I;If the same,write"SAME AS Sl'CF"across tliis section, Be sure
<br /> to check TANK OWNERS TYPE:box.
<br /> IV.BOARD OF EQUAI.IIATION UST STORAGE FEE ACCOUNT INIUMBER(VIUST BE COMPLETEM,SIE}E ARITCL,E 5,C CAVI ER Ci 75,
<br /> DIVISION 20,CALIFORNIA llf.'iALTJI AND SAFETY CODI3.)
<br /> Eruct your Board of Equalization(1,301.')UST storage fee account number which is requited before your Jx;rrnit apphca6on can be processed,
<br /> Registration with the BOE will ensure that you will receive a quarterly storage fee return ill ropirtntg the SOJYJ6((imiil,)1;er gallo>rt fcc dile on the;
<br /> number of gallons placed in your L STs. The 1301:will code persons excrript from paying the slc?rtil;e fee so rooIris ,via r,ot t'c sollt ff you do not
<br /> have an account number N, ith the 130Ei or if you have any questions regarding the fee or cru tt�tion;,please call tl;:;R01:at 916-322 9609 or write
<br /> rota the BOLE at the followhtg a:?:Iress Board of.'1?tlualization,h'aeI'Caxcs Division,I'.C).13c�x 912ii79,5.�cruncn�i? C:.A c)'��i'�t1ti01
<br /> V. PETROL I::U\I LJsl F1NANClAl.RESPONSIBILITY(INIUS('131:COXIPLI.TIED FOR 1'E I RC.LFUM t,!S'l g ONLY,S;a`.Sl,CI 10NS 2711 (aa)'X)
<br /> OF nri..E 23,CHAPTER 10,CALIFORNIA COL)iE OFREGULATIONS.)
<br /> Identify the.mh;t.h(A(s)used by the owner andior operator,in meeting the Federal and Suite financial rcslpolrsibiHiyr.au,r,.r,��.ats: LiSTs ooi=r,cJ by
<br /> any Federal or State agency as well as non-pctrolitent UST:S arc exempt fre>rn this rcgulrt;meiat.
<br /> VI.LEGAL.NOTIFICATION AND BILLING ADDRESS
<br /> Check ONEBOX for the address that will be used for BOTH LEGAL AND BILIANG NOT1HCAl loNS.
<br /> TANK OWNER OR AC THORIZ1:D REPRESENTATIVE MUSTSIGN AND D ATE..TlzIE FORM AS l.ND1C A 1'1:1). ISi..i SLC..IONS 2711
<br /> (a)(13)OF TH LE 23 CIIAP"1'ER 16,CALIFORNIA CODE OF REGULATIONS j
<br /> INSTRUCTION FORT)IE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State L3oard(916)227-1303. 1 horoc Ii r:ombct may be
<br /> assigned by the,local agency;however,this numbermust be numerical and cannot contain any alphabct.ical cliaract.ers. It the:local agency prefers
<br /> the State Board to assign the facility number,please.leave it blank.
<br /> IT IS '!TIIE RESPONSMILPTY OF'TIIE LOCAL AGENCY THATINSPECTS THE FACILITY TO VERIFY THE ACCURACY OF TIIE
<br /> INFORMATION'. T1 HS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMB ER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE- FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY` INFORMATION BOX AND FOR
<br /> I-'()ILW Altl)lN(1 ONIE I Olt\i" "A\D ASSOCIA'1'I3D FORM"B"(s)TO THF FOLLOWING AI)DRI'sSS. 'HIE LOCAL AGENCY SHOULD
<br /> R1ETAIN TIfL;ORIGLNAI S AND FORWARD THE YELLOW COPIES 1'O THE FOLLOWING ADDRESS.111E PINK COPY SHOULD BE
<br /> RF.'TAINIED BY TIIE TANK OWNER.
<br /> 3;93 FOR012ORI
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