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<br />INSTRUCTIONS FOR COMPLETING FORM "Alt
<br />GENERAL INSTRUCTIONS:
<br />Sq CTION 271 i OF TITLE 23, CHAPTER 16.CALIFORNIA CODE DEREGULATIONS AND SECTIONS 25286, 23287„0.ND 257,-9 OF CHAPTER
<br />6,7, DIVISION 20, CAL TFOR IIA HFALTI1 ANIS SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPER A'I !NG, PERMIT,
<br />i. One FORM "A” shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANCES,
<br />2. SUBMIT ONLY ONE, (I) 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 LOC'AI, AGENCY UNDERGROUND TANK INSPECTOR,
<br />4 Please type or print clearly ail requested information,
<br />5, Use a hard point writing instrument, you are traaking 3 co its:
<br />6. Tank owner trust 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)(S), CCR].
<br />7. Tank owner must submit documentation shoving compliance with state financial responsibility requirements to the local agency as part of the
<br />application for petroleum LSTs [Section 2711 (a)(] 1), CCRI, _
<br />"]"CFI' OF FORMS "MARK ONLY ONE I'T'EM"
<br />Mark an (X) in the box next to the 'stern that Best describes the reason the form is being completed. q
<br />1, FACILITY/SITT' JNFORMATION & ;ADDRESS (MUST BE COMPLETED)
<br />I. Record name rind address (physical location) of the underpronate] tank(s).
<br />NOTE: Address MUST have a valid physical location including city, state, and zip codc,.
<br />P.O, BOX NUMBERS ARE NOT ACCEPTABLE.
<br />Include nearest cross street and name of the operaror.
<br />2. Phone number must have an area. code_ If the fright. numb r is the sante, write "S A 117" in proper location.
<br />3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, eic,),
<br />4. Check the appropriate box for TYPE OF BUSINESS,
<br />5. if Facility/She is located within an Indian reservation or other Indian trust ]ands, check the box cranked 11YES",
<br />Ca. Indicate the NUMBER of TANKS at this SITE,
<br />7_ Record the E..P.A. ID #car write "NONE" in the space, provided.
<br />II, PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete all items in this section" untess all ilarns are, ,ftp =arnc a,s SECTION I; If t c ,3..,., e, , rh "S AIME AS SITE„ across th.s section, Be sur;
<br />to check PROPERTY OWNERSHIP TAPE box.
<br />iii. TANK OWNER INF()RfIATI(SN & ADDRESS (MI S -r BE COMPLETED)
<br />Complete all it+.suis in tins sr tion, r rti; s:. all Rectus tare the same La SECTION 1; If tlae sant] .,trite; "SAME AS SITE °' ar ros: this a cticn, Be sura
<br />to check TAMC OWNERS TYPE box,.
<br />IV. BOARD OF EQUALIZATION IST STORAGE FEE ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6.75,
<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 ensLte that you will receive a quarterly storage fee rctum in reponing the ler gallon fee Clue on the aruunber of
<br />s'ahons placed ars your UST,. The BOB will code persons exempt from paying the gwr-ag e fce so returns will not: be sent. If you do not have an
<br />account munber with the BOE or if you have arse questions regarding the fee or r eernplions, pleae call the BOE Qat 916-1 W 'JM,6,e or write to the
<br />BOEat tine ftollowinz ac.d:ess Board of f lualization, Fuel Taxes Di isinta, P,i). Box 942879, Sacrruncnto, CA 90179-,00,01.
<br />V, PETROLEUM I. sT FINANCIAL RESPONSIBILITY (MUST BE (:OMPLETED FOR PETROLEUM UST," ONLY. SEF, SECTION'S 2711 (a)(I l )
<br />F TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS,) -
<br />Identify the; Knethod(s) used by the owner and/or operator, in meeting the Federal and State financial esporlsibifily rcquir g tints. USTs owned by
<br />any Federal or State agency as well as non -petroleum USTs are exempt from this requiremont,
<br />iii. LEGAL NOTIFICATION AND BILLING ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGAL ANIS BILLING NOTIFICATIONS,
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATE[), [S.EE SECTIONS 2711
<br />(a)(135) OF TITLE 23 CHAieTER lis, CALIFORNIA CODE: OF REGULATIONS,]
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdicuon numbers are predetermined and can be obtained by caailin the: State Board (916) 227-4303 Tho fac, b y nurnbr pray
<br />be assigned by the local agency; however, this number must be numericaland cannot conium any alphabat:cal characters, If the local agency
<br />prefers the State, Board u) assign the facility number, please leave it blank.
<br />6195
<br />IT IS THE RE.SPONSIBIL.ITY OF THE LOCAL AGENCY THAT INS:1 E'CIS THE E c AC il._l'1 t TO kh'a ': 1;, .azW-"A,mACY OF THE
<br />INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NL;I� B ER IS NOT FILLED IN, THE LOCAL
<br />AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TI -IF "LOCAL AGENCYUSE 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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