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INSTRUCTIONS I q "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SE:CTfON 2711 OF TITLE 23,CIIAPT?R 16,CALIFORNIA CODE QF REGULATIONS AND SECTIONS 25286,25287,AND 2.5239 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE RrQC,TRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> As
<br /> 1. One F8RN`1"A"shall be completed for all NEW PERMIT C 3IANGLS or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. S'UIRAIT 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 PF',RN1IT APPLSCAXT or the LOCAL AGENCY UNDERGROUND TAMC Zig PEC 1"O .
<br /> 4. Please type or print clearly all requested information
<br /> r
<br /> 5. Use a hard point westing instrument,you arcmaking 3 copies.
<br /> 6. Tank owner must submit,a facility plot pian to the local agency as part of the application showing the:location of tate US`E`s with respeet to
<br /> buildings and lardnarksS7ctksat 27110)($),CCR}. - >
<br /> 7. Tank,owner must.submit documcnta6on showing compliance with state financiat'respon'sibi3'ity re:quitements tri the:Icocal agency as part of the ry
<br /> appFicaczoaz f r trill an US'1 s Seta 1 n' i t(a i 1} C, CRl.)C
<br /> ,
<br /> TOP OFFORNIt " ARK ONLY ONFITE I°`
<br /> Mark an(X)in the be;x next to the item that best describes the reason the form is being completed
<br /> I. EACILI'I°YISI E INFORMATION&ADDRESS(MUSTER ER CC}:$.rII'I ETED)
<br /> I. Record name and address(physical Iolgation)of the undergneoiu tank(s).
<br /> OTE:Address MUST have a v;alU physicai location including city,stare,and zip code.
<br /> T' O.BOX NUMBERS ARE NGT ACCFlYFABLF.
<br /> Include nearest cross street and narne of the operator,
<br /> 2. Phone nurnbcr must have an area c<xic:. If the nip ht number is the same,Write"" AMt,"in proper location,
<br /> 3. Check the appropriate box for'I'YPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF 13USINESS.
<br /> 5. If Facility/Site is located within art 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 4 or writ "NOINE"in rite,space provided.
<br /> IT. 1'1IC11'1.,"R'I'Y OVk'<LI'INi C)RN4A rI<,PN Sa ADI),dlwSS(AI' S3 IiE CC)MPI I IED)
<br /> Complete all irculs in that sccd DS unless all item,etc the same as SEC I IC}N 1;If the snare,Write SAN4E,A E acros.'R 1
<br /> to check PROPERTY O S ERSIlil?"t'''PE lox
<br /> III, I A K OWNER INFORMATION&ADDRIESS('v u—S I REs C:C3MPL.E;11..D)
<br /> Complete all items in this section,unless all itetus are the s:arne as SECTIONr1;If the,same,write, Sail AS SIT!' arras Lhir secticln, Re satire
<br /> a '110( T ASR OWN "3`A 1 ry b€ca, �t
<br /> IV.BOARD 01"EQUALIZATION UST S'I GIC ACTT FEF zACC".GL,N'I INUM131 R.(MUST BE C:C3MPIJ1'.I F:D.SEE ARTICLE 5,CI APfI3R 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> Eater VOW 13u,ard Of Leta,.iraticni(130:.)UST storage,fee account number which is required before your p erotit al plie"Ation can be;ptoctsscu,
<br /> Rc flora€ion ss oh tits BOE will:nswe,ih,t,you will receive a Guancdy storage fee return in reporting the S0 0)6(6url€1,,,
<br /> number of gal lons pi aced in y ol11 s,S I's. =e,- Jl;will cc, e}xtso s cxe.r:pt from payinz;the sr�rapc iee'scs r t. a> _1 .��+ 'Cf s>t;ilea tt
<br /> have rata ac,"o c rt number wish the I3Cti�oo i=)'uu haa,arty gtaeseicraas re gar ling the fee or cxcsnivi t,s,picasu c.Al i;e,BOE al,91 f, 22 )669 or rite
<br /> to the BOF thc following addres IloaEd of Fuel Taxcs Division,P,O,Box 942579,Sacr.wne ao,CA 9 _, ;
<br /> V. PEIiZC.iLF )>1 t,>:`FIN CAI tiF 'IONS.,31i ITT(Ml_-,s'3 I3i:.CC)1IPLEi"T`D I"OR PEI RC)LE 4I USTs();5IN,S..l..;;.0 I10-;.`I2711 (a;01)
<br /> OF'3I1 LI,23,CHAP`E"it 16,t':A1,I1 OiCNIA CODE,OF_RE'GUILA IONS.)
<br /> Ice t,i`y the.netl.ex:,$),a:cd b t hcowner anXor opciator,in meeting Ehe Faedr sal and State:financial re:spor stl el,ty s; ,tt�a ._ :ah, o STs �,d 2)v
<br /> any a edeft w St.iie ag,U,ncy as w e[l as stun-p ro: =tt t!S"[s<a, exempt from this rutin❑i
<br /> VI.I,E'GAL NO 011 aCA TION AND EIILLIN(3 ADDRESS
<br /> Check ONE.BOX for the address that will be used for BOTH LEGAL AND
<br /> Ei 1 Lh4< CCJ"1'1E�tICA"I"l(;y
<br /> "1:�'�'3{C3SA�I>R CEiZ At"PEI ),s'l1.LD ll1 l'_311`3i2A"TA°I'IA'E ihilST„calCiX Ari�`E)Z)AT L Tllli Eat:)iZy1 A�lNl)IC�AI'1,1). „�a:.T'`a_1<:1?G?S 2"7 t F
<br /> (a)(13)OF I1'[LE 2J CJIAPTa_R 116,C 'eL.I€°OR,'N'lA COVE OF RFIGLLA°T"IO S,
<br /> The county an 3ri6sdiction nurnlx:rs are pre determi,o d and can be obtained by calling the Stats,Board(916)227-43{l3. I Ise f<_ilily number may Esc
<br /> assigned by the bxJ A a€>rncy9 ho,,Iever,this stunt}tier must€aenurnerical and cannot comain any.alphaY e;tic:al charaetcrs. If the,local agency IsrcCcrs
<br /> the State Board to assign the facility nt.cnber,please leave it blank.
<br /> IT Is TI111, RESPONS1113111TY OF THE LOCAL AGENCY THATINSPECTS THE FACILITY TO VERIFY THE,ACCUTR AC Y OF TIM
<br /> INFORAIAT'ION, '['!!IS APPLICATION CANNOT BE PROCESSED ITh TI IEi BOE r C::COUN t'N(1II3ER IS NOTFILLED ED INi '17111 LOCAL
<br /> AGENCY IS RhSlI0, SI BLE FOR TIlF C ON11ILLT•IO OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONT:FORM,=A"AND ASSOCIATED FORM"13"(s)TO TT["FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN]HE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWLNG ADDRESS.TATE PINK COPY SHOULD BE
<br /> RETAINED f..3Y THE TANK OWNER.
<br /> sTAT'E,,QF CAE,IFQRNIA
<br /> a
<br /> STATE WATER 12E.. URCE?S CONTROL.BOARD
<br /> C/0 S,W.E,E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.D.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3;93
<br /> FORwolli
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