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<br /> INSTRUCTIONS FOR COMPLETING FORM rrts
<br /> $ GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLES 23,CHAPTER 16,CALIFORNIA CODE OFF REGULATIONS AND SECTIONS 25286.25287.AND 25289 OF CHAPTER
<br /> APTE;
<br /> 6,7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY COBE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or anyFACILITY/SITE 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 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 Calan 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 UST-,[Section 2711(a)(11),CCR].
<br /> TOP OF FORM."MARK ONLY ONE ITEM"
<br /> Mark an(X)in the[sox next to the item that best describes the reason the Farm is being completed.
<br /> 'I. FACILITY/SITE INFORMATION 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 crass 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 the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box markLd"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 /> II. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETE!))
<br /> Complete all items in this section,unless all items are the same as SECTION 1,If the same,write"SAME AS SITE"across this section, Be 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 l;if the same,write"SAME AS SITE"across this section, Be sure
<br /> to check TAN!{OWNERS TYPE box.
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE E 5,CHAPTER 6,7 s,
<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 will receive a quarterly storage fee return in reporting the per gallon fee clue on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt from paying the storage fee so returns will not be sent.
<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 writs to the
<br /> BOEat the following address Board of Equalization',Fuel Taxes Division,P.O.Box 942874,Sacramento,CA 94279-�I001.
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY.SEE SECTIONS 2711 (a)(1 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 4luirements.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 ON TBOX for the address that will be used for BOTH LEGAL.ANIS BILLING NOTIFICA'T'IONS.
<br /> TANK.OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711
<br /> (a)(I3)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)227-4307. The facility number may
<br /> be assigned by the local agency,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 RESPONSIBILITY OF THE LOCAL AGENCY THAT" INSPECTS THE FACILITY TO VERIFY THE ACCURA Y•OF,THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT`NUMBER I4 NOT TILLED 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,
<br /> }l4 .ryy.
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