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<br /> INSTRUCTIONS FOR COMPLETING Aff
<br /> Cil NERAL INSTR13CTIONS:
<br /> SECTION 2711 OFTITLE 23,CHAPTER iii.CALIFORNIA CODE OF RRC',ULATIONS 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 /> 14 One FORM"A"shall be completed for it NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2, SUBMIT ONLY Y ON (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 PERMIT APPLICANT.or the LOCAL AGENCY UNDERGROUND,TRNK INSPECTOR.
<br /> 4. Please type or print clear(}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 applicaiion 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 showitlg compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711 (a)(I1),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 forth is being completed.
<br /> 1. FACILITY/SITE INFORMATION cid ADDRESS(MUST BE COMPLETED)
<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 nearest-cross street and name of the operator.
<br /> Z. Phone number must have an area code. °If`xhe maht'number is the same,write"SAME"in•proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate boy;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 /> 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 /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the snrne as SECTION l;If the same,write"SAME AS SITE"across this section. Be sore
<br /> to check PROPERTY OWNERSHIP TYPE:has,
<br /> 111;TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this seraical,unless all iternt 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 OF EQUALIZATION LST 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)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure that}you xill receive a quarterly storage fee return in reporting the per gallon Pee due on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt irom paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOE or of you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOB at the following address Board of Focalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL,RESPONSIBILITY(MUSTBE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)('1 I)
<br /> OF TITLE 23,CHAPT17R 16,CALIFORNIA COBE OF REGULATIONS.)
<br /> Identify the medaod(s)used by the owner andtor operator.in meeting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AMITY BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN.AND DATE TETE 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 localagency;however,this number must 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 RESP}NSISIL££ OF THE LC_,Al, ,k(.E,as, Tb,«rECTS
<br /> :. e4.Ari x�r T.rE FACILITY'TO VERIFYTHE ACCURACY flI~ '.
<br /> 'INFORMATION, THIS:APPL,IC,ATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL,.
<br /> AGENCY.IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY'USE ONLY" INFORMATION BOX, THE LOCAL.
<br /> AGENCY SHOULD RETAIN THE, OPIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANIC
<br /> OWNER.
<br /> x,95 _
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