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INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMITCHANGES or any FACILJTY/SITE INFORMATION CHANGES. 2. SUBMIT 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 PERMIT APPLICANT or the LOCAL 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 fSection 2711(a)(8),CCRJ. 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)(I1),CCRJ. TOP OF FORM:"MARK ONLY ONE fI'EM" Mark an(X)in the box next to the item that best describes the reason the form is being completed I. FACILITYISITE INFORMATIONr&ADDRESS(MUST BE COMPLETED) L 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 ACCEPTABLE. 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. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.). 4. Check the appropriate box for TYPE OF BUSINESS. S. 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#or write"NONE"in the space provided. II. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) Complete all items in this section,urdess all items are the same as SECTION 1;If the'same,write"SAME.:AS SI`Z'E"across this section. Be sure to cheek PROPERTY OWNERSHIP TYPE box. IIL TANK OWNI'R INFORMATION&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 TANK OWNERS TYPE box. IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOL NT NUMBER(MUST'BE COMPLETED.SEE ARTICLE 5,CIIAPTER 6.75, DIVISION'20,CALIFORNIAHEALTH HEAH AND SAFETY CODE.) Enter your Board of Equalizatior.(1301')UST storage fee account number which is required before your permit application can be processed. Registration wuh the 1301'w ill ensue that you will receive a quarterly storage fee return in reporting the$0.(X)6(6mills)per gail<ni fee due on the number of gallons plac:cd in,,your U. Ts. The BOE will code persons exempt from paying the storage fee so returns will ncit br,sent. If you do not have an account number with the 130E or if you have any questions regarding the fee or exemptions,pleas;call the BOT:at 916 322-9609 or write to the BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 91210 00'ol. _ V. PE"IIZULEUII L;S'1'FLSANCIAE..Et1iSl'ONSE.1?ILI"I1 (A1UST BLi COMi'LET'ED FOR PZIROLfiLM.USTs ONE,)',SEL., I:C:"I[O\S 2711 (a)(3), OF TIT LFl 23,CHAPTER 16,CAI:FORNIA CODE OF REGULATIONS.) Identify the ntetl:ix2(s)used by Lht�owner and/or operator,in it'teeting the Federal and State financial responsibility r .Iuircrtwits USTs orsred by any Federal or SLate agency as well as non-petroleum USTs are exempt from this requirement. VI.LEGYAL NO`IIFICATION AND BILLING ADDRESS Check ONE BOX for the address that,will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AUTHORIZ.I:iD REPRESENTATIVE MUST SIGN AND DATE THE FOR:tt AS INDICATED. ISE]-Si.(;`ITO tiS 271.1 (a)(13)OF TITLE 23 Cl1APTIiR 16,CALIIFORN'IA CODE OF RE.GULATIONS.] INSTI2liC['ION I t)IZ'I'III LOCAL AGENCIES The county an jurisdiction nurnEwrs are predetermined and can be obtained by calling the State Board(916)2274303. The facilif number may be assigned by the local agcncy;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OFTHE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT.NUMBER IS NOT FILLED IN. THELOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL,AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RL'TAIN T HE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE RETAINED BY TILE 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 FOR012DRI