|
INSTRUCTIONS .: "A"
<br /> GENERAL AL.INSTRUCTIONS:
<br /> SECTION 271 t0 'TITLE 2.1,Cf i ATTR l6,CALIFORNIA CODE OF REGULATIONS AND SECTIONS'5256,25257,AND 25259(3F CHAPTER6.7,DIVISI5�?4',�Sl`CALIFIORNTA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> f. One FORM"A"shall be completed for all NEW PERMIT"CHANCES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facili€y/Site,regardless of the number of tanks located at the site.
<br /> 3. This farm should be completed by either the PERMIT"APPLICANT 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 making 3 copies.
<br /> 6, Tank owner must submit a facility plot plan to the local agencyas part of the application showing the location csf the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(IT),CCR).
<br /> 7. Tank owner must submit documentationshowing compliance with state financial responsibility requirements to€he local agency as past of the
<br /> application for petroleum USTs[Section 2711(a)(]1),CCR].
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(k)in the box next to the item that best describes the reason the form is being completed,
<br /> L FACILITY/SITE INFORMATION&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 locations including city,state,and zip code,
<br /> ROC BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone nu€nber must have an arca.code,. If the night number is the same,write"SAME"in proper locitiom
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4, Check the appropriate box for TYPE OF BUSINESS.
<br /> . If Facility/site is located within an Indian reservation or other Indian crust lands,check the box marked"YES"
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.I19#or unite"NONE"in the space provided.
<br /> ti. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete alt items in this section,unless all items are the Sas eras SECTION 1;If the sanne,write`SAIM AS SITE"across this section.Fie sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III.TANK 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 SIT"E"across this section. Be stare
<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 SAF"ET"Y 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 t hat you will receive a quarterly storage fee return in reporting;the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOB will code persons exempt frorn paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOB or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 01,write to the
<br /> BOE at the following address Board ofEqualization,Fuel Taxes Divisiou,RO" Box 942579,Sacramento,CA 94279-0001,
<br /> V, PETROLEUM USTFINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I 1)
<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;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 061E BOX for the address ghat will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR AUT OR12ED REPRESENTATIVE MUST SIGN AND DATE 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(9I6)227.4303. The facility number may
<br /> be assigned by the Ioca1 agency;however,this number must be numerical and cannot contain any alphabetical characters. If the localagency
<br /> prefers the State Board to assign the flue iluy number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS TITE FACILITY TO VERIFYTHE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT"BE PROCESSED IF TETE FOE 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 SI-buLD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> a
<br />
|