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INSTRUCTIONS FOR COMPLETING FORIM "A"
<br /> GENF SAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 2:3,CHAPTER.16,CALIFORNIA CODE OF REGULATIONS ANIS SECTIONS 252$6,25287,AND 25289 OF CHAPTER
<br /> 6,7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST CII'R'RATING PERMIT,
<br /> 1, One FOR vI„A>,..shall be completed for all NEW PERMIT CHANGES or any FAC;IL.I"TYISITE 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 PERMtIT APIPUCANT 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 snaking 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the lopal agehey as part of the application showing`the:location of€he`USTs wilh 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'thc
<br /> application for petroletam USTs[Section 2711(a)(11),CCRI.
<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, FACILITYISITE INFORMATION&ADDRESS(DUST BECOMPLETED)
<br /> I. 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,neamst cross street and name of the operator.
<br /> 2. Phone number must have an area trade. If the night number is thesame,write,"SAME"_in proper location,
<br /> 3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> , Check the'appropriatckbox for TYPE OF BUSINESS:
<br /> 5. If Facility/Site is located within an Indian reservation or tither Indian trust lands,check the bora marked"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 /> TI. PROPER'T'Y OWNER INFORMATION&ADDRESS(MUST BE COMPLETE[)) �
<br /> Complete all items in this section,unless all Mems are the same as SECTION 1;If the same,write"SAME A5 SITE"across this section. Be snare
<br /> to check PROPER'T'Y OWNERSHIP TYPE box.
<br /> "Ill.TAMC OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> C;onmple€e all"items in this section,unless all items are the same as SECTION 1;If the same,write",SAMCE AS SITE"across this section. Be,sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV,BOARD OF EQUALIZATION UST"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)UgT.storage fee account number which is required before your perant application can be proues'sed.
<br /> Registration with the BOE will ensure that you'will receive a quarterly storage fee return in reporting the per gallon fee clue q the number of
<br /> gallons placed in your USTs. The BOB will code personas exempt from paying the storage fee so returns will not`be sent: 'Fd rou do"nothave an
<br /> :account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> EOE at the followi4 address Board of Equalization,Fuel Taxes.Division,P.O,.Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM UST FINANCIAL.RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State Trnah6al responsibility requirements,UST's o�Aecllby n°
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement. 9,°
<br /> VT.LEGAL NCITIFICATION ANIS BILLING ADDRESS
<br /> Check O BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANIS LATE 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, Tile facility number craay
<br /> be assigned by the local agency;however,this number must be numefical 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 NUMBEW15 NOT FILLED IN, THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF T14E "LOGAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULDBE RETAINED BY TIME TABIC
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