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INSTRUAONSFORCOMPLETING F Am" gy=p
<br />GENERALINSTRUCTIONS:
<br />UCTIONSa
<br />SECTION 2711 OF'I TLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS TIONS AND SECTIONS 25286, 25287, AND 25289 OF CTIA.PTER
<br />6.7, DIVISION 20, C .LIVOR -NIA PTEA I:FlI ,AND SAIFTY CODF REQUIRE OWNERS TO APPLY FOR AN UST C)PERA' TNG PERMIT,
<br />L One FORM "A" shall be completed for all NEW PERMIT CHANCES or any FACILITY/SITE INFC}RMATIiON CHANGES,
<br />2, SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tarots 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, yo are making 3 copies,
<br />6. Tank owner must submit a facility pint plan to the local agency as part of the Application showing the location of the US €'s with respect to
<br />buildings and landmarks [Section 2731 (a)(g), CCR].
<br />7. Tank owner must submit docurnenta6d a showing compliance with state financial responsibility requirements to the local agency as part cf th€;
<br />Application for petroleum USTs [Section 2711 (a)(l 1), C~CIZ.I.
<br />TOP OF FORM: "MARK ONLY ONE ITEM"
<br />Mark sin (7C) in the box next to the item that best describes the reason:the form is being completed
<br />L FACILii"Y/SITEa 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 />RO, 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 4OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />4, Check theappropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES".
<br />6. bidicate the NUMBER of TANKS at this 511`E.
<br />7. Record the E'-P.A. ID # or write "NONE" in the space provided.
<br />II. PROPE,,RTY COY `;ti EKI.NIFORIv1t1'l ION & ADDRESS (MUS1' lila C'C).v1I'LE I'I D)
<br />Complete all items in this secuort, unless all items are the same as Sh,C PION 1; If the same, write "SAME ASSITE" across this scction, Be sure
<br />to check PROPERTY OWNERS IIP TYPE box,
<br />JII, I ANK OWNER INFORMATION I`I%IN & ADDRESS (MUST BE COMPLETED)
<br />Complete all kerns in this section, unless all items are the sarne as SE,%'I°IO?+i 1; If the same, write "SAME AS SITE. acToss this section'' Be 8111u'
<br />to check T'rANK Cil N'ERS,'I`YPE box,
<br />IV. BOARD 01' I:QUALiZA`I I ON UST STORAGE FE:E ACC(AiNT NUMBER (MUSTBE COIMPLE.IEM. SIT"AR-1-ICLE 5, L.;IIA;`I'1,1:R g ,75,
<br />DIVISION 20, CAI ..,I['CORNIA IIEAL`I lI AND SAFETY CODE.}
<br />Enter your Board of Iy taliz aiion (BOE) UST storage fee account number which is required before your Ixmnit .application cart I,e Iii"c>z sY.^si.
<br />Regis}:ration with tha BOE will ensure that you will receive a quarterly storage; fee reium in rcporning the, S0.(h)6 ((nnil'ls) pc[ , dl,ia fir., ._,ae t.rj tix;
<br />number of gallons placed in your 1.15'I's. The BOF, will code persons exemptfrom paying they Storage fcc so rckurats will rtct hr If you do sa„
<br />have. an :account number with the BOE or if, you have any gtaestions regarding the fee or exenrnpl ions, please, call the BOIa :at 91 6-322-1X)69 of v, a<i
<br />to the BOL at the following address Board of Equalization, FuelTaxes Division, 11.0. Box 942879, S;acras,asaao, CA 942';`, W01
<br />V. Pk:IRO EU3 USTFINANCIAL (.'MUST BECONIPLI.-'TED FOR Pl..i'R(Ol:.FUM C aTsONLY,SIX711 OS 2711
<br />OFTITLE E 23, CHAPTER 16, CALIFORNIA CiODFIl OF I FGUL.A-f IONS.)
<br />Id t..f`y ai c xt , ilCnllsj tscd i>y
<br />the e>evncr And/or operator, in mcctatag theFederal and :state f st7sat.caa3
<br />I c
<br />any Fedet>al or Sunc. agency as well as non-petrolcaunUSis are exempt from thzs rcquiretttent_
<br />VI, LEGAL t`m01 IFICATi ON AND BILLING ADDRI3SS
<br />Cho. k ONS; BOX for €he° addre°ss Haat will be used for 13C3TH LEGAL AND KILLING
<br />TANK OvVNE.R CHIC:tU'I'IIiJil.l'GL:i9REPRESENTATIVE, MUST SIGN AND L>AT llita lrC)RM AS INDIf:A 1 L!)t� `;f, _ . o _S '2'Y
<br />= t
<br />(a)(13) OI I i"I'LE 2.3 Cl [AP ER 16, CALIFORNIA CODE OF REGULATIONS.]
<br />Ii°CSTRUCTION FOR'IH , LOCAL AGI.,"NCIES
<br />Thr, county au jurisdiction nurn,Lrs are ptcdetermined and can be obtained by calling the State Board (9 16) 227-4--01. i hu ni e s m xis
<br />assigned by the local agency; however, this number must he numerical and cannot contain any aipn,al)eiee:ll chw4ct r .. of Isle local Wore, i pw �,-az
<br />the Sta c Board to asci n the facility ntarnber, pleaseleave it blank.
<br />IT IS THE RESP0NS:l3lITFY tOF'T`HE LOCAL AGENCY THAT INSPECTS TB, FACILITY TO Vl;ld IFY THE ACCI RAC..Y OF 'ME
<br />INFCOICMA!`ION, I'll! i APPIACATIiON C'ANINO`I" BE PROCESSED SSED IF THE BOE ACC(3L .NT NIJM111 t 1S N' O`I' I ILLED IN: °T l it<'. L()t:° AI.
<br />AGENCY IS ItlwSl't) SII3I.E: ICOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY` INF OItYtAT1 Oi,' BOX AND 1018
<br />FC RWARI:)ING ONE' FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING AIODRE'SS. THE I-OCAL AGENCY SHOULD
<br />RI:I`AIN `lHE ORIGI]NAUS AND 'FORWARD THE YELLOW COPIES 'TO IIEl roLLOWING ADDRF.iSS.'IHE PINK COPY S1101.,I.1, BE,
<br />RETAINED i3Y TIil: TANK ,')ia/,S E R.
<br />STATE OF CALIFORNIA
<br />STATE `N` ,TF.R RESOURCES'CONTROL BOARD
<br />CICS S:W.E,EP.S:
<br />DATA R OCESSLNG CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90723
<br />3.93
<br />.. FOR012081
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