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INSTRUCTIONS FOR CONNIPLETING FORAI "A"
<br /> GENERAL NS "RUCTI NS:
<br /> SECTION 2711 OFTITLE 23,CHAP "ER 16,CALH,0RNIA CODh OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODEREQUIRE OWNERS TO APPLY FOR AN UST OPERATING T;ERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITYISITE 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 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 pica€glary to the local agency as part of the application showm.g 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 /> j application for petroleum USTs[Section 2711(a)(I 1),CCR],
<br /> TOP OF FORM:"IMARK ONLY ONE I'T'EM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tanks).
<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,unite"SAME.°"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc,).
<br /> 4. Check the aPP appropriate riate box for TYPE OF BUSINTSS.
<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 TAINS at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> IL PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all itenss in this section.unless all items are the same as SECTION 1:If the same,write"SAME AS SITEE'across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> Ill.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the Sarre as SECTION 1;If the same,write"SAME AS SITE"across this section. Be:sure
<br /> to check TANK OWNERS TYPE box,
<br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5.CHAPTER 6.75.
<br /> DIVISION 201,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Tinter 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 slue 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. 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 BOE at 916-322-9669 or write to the
<br /> BOE 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,SEF 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 ANIS BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATION&
<br /> TAMC OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND BATE 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)227-43073, Tire 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 V'ERIF'Y THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION 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 ORIGINAL AND YELLOW COPIES, TIME PINK.COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> &95
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