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� � INSTRUCTIONS FOR COMPLETING FORM "Alt GENERAL INSTRUCTIONS: SECTION 2711 OF "I'I"I'LE 23, Cl I APTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 2528(:25287, AND 25289 OF CHAPTER . 6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FOIUM "A" shall be completed for all N EW PERMIT CHANGES or any FACIL Tl"Y/SrrE INFORMATION CHANGES. 2. SUBMrr ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the site, 3. This form should be completed by either the PERNirr APPLICANT or the LOCAs. AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information" 5. Use a hard point writing instrument, you are making 3 copies. 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 buildings and landmarks [Section 2711 (a)(8), CCR]. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs [Section 2711 (a)(11), CCR]. TOP OF FORM: "MARK ONLY ONE TI'E,44" Mark an (X) in the box next to the item that best describes the reason the font is beim. completed I. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) 1. Record name and address (physical. location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACCElyrABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location. 3. C'he'ck the appropriate box for TYPE OF BUS]\ESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.). 4. Check the appropriate box for TYPE OF 13USINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID fi or write "NONE" in the space provided. 11. PROPERTY OWNER LNtFORMATTON & ADDRESS (MUST BE COMPLETED) 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 to check PROPERTY OWNERSIIIP TYPi box. III. TANK OWNER INFORMATION & ADDRESS (MUST 13E COMPLETED) 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 to check TANK OWNERS TYPE box. IV. BOARD OF EQUAI._IZATTON UST STORAGE FEE- ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CIIAP1ER 6.75, DIVISION 20, CALIFORNIA IIEALTII AND SAFIrI-Y CODE..) linter youra3oard of Equalization (BOE) UST storage fee account number which is required before your*nnit application can be. procc�sed. Registration with the BOE will cn urc that yeti will. receive a quarterly storage fee return in reporting the SO.W6 (brr;ills) InT galhm fee• due on the number ofgallons pJaccdirt4vru UShs. Ilte 13"013 «yi.11 �;odc persons exempt from paying the storage fee sci rctums vrifl not Ire scni. If you do not have an account number with the BOE or if you have any questions regarding the fee or exetnptiotts, please call the 130E at 910 3'_'2-9669 or write to the 13011, at the folloH'ing address Board of Equalization, Fuel Taxes Division, P.O. Box 942879, Sacramento, CA 912'r9-;,00;1. V. PET ROLEUA1 US I'FINANCIAL RESPONSIBILITY (NIUST BE CONIPLE"11-13I-OR PET'ROLEUNI UST's ONLY, SLIE, BECKONS 2711 +.a)(9.) OF TITLE 23, Cl IAP 111-R 16, CALIFORNIA CODE OF RL'GULATIONS.) Idem ify the ntcthod(s) used by t : owner an dlor operator, in meeting the Federal and Statefinaneial responsibility rcyt it ,u:: tt . US_ TS ov ned by any I'edc•.rd or State agency as well as non -p troieum USI's are exempt. from this requirement. VI. LEGAL N0111 KATIONAND BILLING ADDRESS Check ONE. BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNEK OR AUTHORIZED RI311Rf.SEN'TATIVF. MUST SIGN AND DATE THE FOILA AS INDICATED. [SE l-' SE C:TI0N'S2711 (a)(13) OF ,nn.r 23 CIIAPT'ER 16, CALIFORNIA CODE OF REGULATIONS] INSTRUCTION FOR THE LOCAL AGENCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. Tbe. Ncrloy nurnber ntay lx assigned by the local agency; however, this number must be numerical and cannot contain any alphabetical characters. of the local urgency prefers the State Board to assign the facility number, please leave it blank. IT IS THE.' RESPONSIBILITY OF TILE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. TI [IS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NU.34BER IS NOT FILL 1--M IN. TIIL: LOCAL AGENCY IS RESPONSIBLE FOR THE C:OMPLEIION OF THE "LOCAL AGENCY USE ONLY" INFOR'NIATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RE"IAI.\ THEA. OR.IGL\ALS AND FORWARD THE YELLOW'COPIES TO THE FOLLOWING ADDRESS. THE PINK COPY SHOULD BE RETAINED BY'lIIL TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 193 FQFi0120Ft