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INSTRUCTIONS FOR. COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23.CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286.25287,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACIL€TY/SITE INFORMATION CHANCES,
<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 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 snaking 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 USTs with 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 the
<br /> application for petroleum USTs[Section 2711(a)(]1),CCR].
<br /> TOP OF FORI'W"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 /> 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 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 /> 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,INDIVIDUAL,etc.).
<br /> 4. Check flee appropriate box for TYPE OF BUSINESS.
<br /> S. 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 unite"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 same as SECTION I;If the sante,write°SAME AS SITE"across this stiction. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION I-,If the same.write"SAME 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 203,CALIFORNIA HEALTH AND SAFETY COBE.)
<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 BOB will ensure that you will receive a quarterly storage fee return in reporting in.per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOB will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOB at 916-322-9669 or write to the
<br /> BOB at the following 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)(i 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,)
<br /> Identify the method(&)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 ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DA'T'E 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)227-43013. The facility number may
<br /> be assigned by the local agency;however,this number must he 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 RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERITY THE AC:CUIRACY OF THE;
<br /> 1NFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB 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 ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
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