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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GE NER ALINSTRUCTIONS:
<br /> SIiC ION 2711 OFTITLE,23,CHAPTER 16,C'ALIFORINIA CODF(V REGULATIONS IONS ANIS SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> (.",T)iVISlON 2C},C"ALIP'CR4IA HEALTH AND SAFF TY CODE REQUIRE OWNS PS TO APPLY FGA' AN USTOPERA'nNGPERMYF, '
<br /> 1, One FORIM„A"shall be cornplev-d for all N'E^W PERMIT CHANGES or an °A€.II=' �'t'�t z 1..i:�?=;4Z :i.=�i It)N CHANCES,
<br /> 2. SUBMIT ONLY ONE(1)CORM"A"for a Faci ity/Site,regardless of the monber of tanks locrrated at the siu%
<br /> 3. This form should bc,completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK IN P'I:L,POR.
<br /> 4. Please type or print clearly all requmstcd information
<br /> S. Use'a hard point writing instrsuxaent,you are making;3 copies, —
<br /> 6. Tank owner must submit a facility plot plana to the local agency as par°of the application showing the location of the USTs with,respeotto
<br /> buildibg and l6dmarks t Section 2711 (a)(S),CCR
<br /> 7. Tank owner no st sines i'<kacaaartac rttatiz n showing cxamplianre with sta€e',financial r€"nsibility requiremenn to thelocal agency as part of the
<br /> application for pctrolcurn UST's I Section 2711 (a)(I I),CCR].
<br /> TOP OF FORJM:"MARK ONLY ONE,ITEM"
<br /> Mark an(X)in the box next to the hem that best describes the reasoll the form is being completed
<br /> I. FACILITYISIT E IN FCIRMA;,O N A,ADDRESS(MUS I'13E CONIPI...ETf Ft)
<br /> 1. Record name rand address,(physic,..a location)of the un€4e%round tank(,).
<br /> 'COTE: Address MUST stave a valid physicaa location including city,state,and zip code
<br /> P.G.BOX NUN113ERS ARENOT AC:CERFAl3L'E,
<br /> Include rarest cross street and name of tlae operator.
<br /> 2. Phorn,nrtribrr meat have an:arca code. I4 the night nuoiber is the same:,writs;"SAME"in properlocation.
<br /> 3. Check the appropriate lox for TYPE OF I3L.SLNLSS OWNERSHIP(ex,CO PC)RfETIQN,INDIVIDUAL,etc,)_
<br /> 4. Chick the appropriate box forT'YPE OF lWSINES
<br /> 5. If Facility/Site is located within;an Indian reservation or other Indian trust hinds,check the box marked"YES".
<br /> 6. Indicate the Nl_;' BI,,R lA TANKS at this SITE.
<br /> 7. Record the ET,A,ID 4 or write"NONE"in ific space provided,
<br /> II_ PROPERTY OWNER INFORMATION&ADDRESS(-NIIJS'I I3l:CC):.k2'PI,ETEL?)
<br /> Complete all items in this section,unless all ites.xs are,the saa'rxe as SECTION 1;If the same;write"SAME AS SITF,"across this sectionBe sure
<br /> to check PR€)PE;liT Y Ll sk N1�RSii[P'I YI'I'tx>x.
<br /> III.TANK OWNER INFORMATION&ADDRESS(i4IUST 13E COMPLETED)
<br /> Complete all items in this section,unless a.1 items are the same as SF:C'IION 1,If the,same,write"SAME AS ST T""across this sec.ciota� Fie sure''
<br /> to check TANK C)W N1,'RS TYPE box.
<br /> IV,BOARD OF EQUAIIZA"I ION 11S`T'S'I"C)RAC,E.FEE,ACCOUNT Nt,`3iBER(SIUST BE,COMPLETED,ETED,S13f: ARTICLE 5,CHAFTER 6.75
<br /> DIVISION 20,C'ALIFC RNIa1 Sil:a L'I'll AND SAFETY C:ODI,,,)
<br /> Fat€cr your Board of F"Ju>1x.ation(Wti)E.ST storage fee account nurnber which is t'cqu:red before yourpennit application can be:processed,
<br /> Registration wish the BOI?grill i;nsme that you will receive a gt,anerly storage fee,return in reporting the$0,0 6(Ornil s)per'gisallon fee rlucs on the
<br /> number of gallons placcd in your GSTs, The BOF,will code Ix,rsons ex.enipt from paying the slog agc.Cee so returns will not be,,sinal. If you do girt
<br /> have art,ac:courn number v.ith 0e BOE to if you have any questions regarding the Ice or excrnptkeiq,picasc call the,BOE at 916-322-9()(0 orwrite
<br /> to the 1100 at the follo"ing addua ,s T3otud of Equalization,Fuel Taxes Division,P.O.Box 942879,S acrameroo,CA 94279-0001,
<br /> V. PlE"IT2C)?.ELM US l l[ ,a C.t;tT all, E'ClN I1i13:I"I'y'(M S"l B E COMPLETED D I OR 111-Fit}I.EUM L'ST1,ONLY,SliE SECTIONS t (a)(9)
<br /> OF T11 `2'3,C11, P ITIR 16,CALIFORNIA CODE,OF152(,LULAIHON"S.) _
<br /> ldcw.,,r the stw1hod{S)u a d t.ay 1he oc ncr an"llor operator,it m w,ng the Fcdcml.and ,in-'.sial t,. ponsib.a=y rccli ` l s s),.F,a;.1 by
<br /> any r cdQi<al car Slaw,a;,,ncy as well:a�nota l etrolcuin US la ar.,cxinnje bent this rrxluiaru,nL
<br /> VI,LEGAL NOTIFICATION AND BILI.iNG ALrDRE'>S
<br /> Check ONE BOX for the ail it�-ss that will he used for 130111 L EIGAL AND BIl.l.ING N'(3l'i"HcA;R)NS.
<br /> TANK OWNER OR AUTIiORVI;l)IshPREISIENTAT IVE MUST"SION AND DAT'Is THE hC)RM AS INDICATED. [SEE,.SEC TIONS 2711'
<br /> (a)(13)OF1111F,23 CHAPTER ER 16,CALIFORNIA COD E CIFE REEGULATIONS.]
<br /> I"'xrS.I`RUC'1'I01ti 101R't'lll=,LOCAL AGENCIES
<br /> S
<br /> The cociwy at)jurisdiction t=ta nlx,:s are prcdctermined and can be obtabled by calling the State Board.(916)227-43113, lbe,faciloy nun-ib rrn;ty he
<br /> assigned try the hovcver,?tris naunbter roust be,maanedcal and cannot contain any alph,alletical characters. HU-10 loc"d agonc}poifc s
<br /> the„chats Board w ass;ega the fac ill>y number,please leave it blank.„
<br /> IT IS THE RESPONSIBILITY OF T'I(E: LOCAL AGENCY TIIATINSTILS'"I s T111E FACILITY TO VIiRI=Y THE' ACCURACY Ft THE
<br /> IINFORMA`iON. "I HIS APPLICATION CANNOT BE .PROCESSED IF THE BOE ACCOUNTINUN4 3ER IS NOT FILLED ED iN. T"CIF`s LOCAL
<br /> AGENCY IS RESPONSIBLE' FOR I'll[,- COMPF.I11ON OF THE "LOCAL AGENCY USE ONLY" INF ORNIA`ITON BOX ANT) FOR
<br /> FORWARDINC3()Nl^1 ORNI"A"AND ASSOCJAIT D FORINI"B"(s)TO THE FC)t,.I.OWING,ADDREESS, THE LOCAL AGENCY S if?TJLD
<br /> RETAIN THE,ORIGINALS AND FORWARD THE YELLOW COPIE s TG fHE FOLLOWING ADDRESS.THE PINK COPY'SHOULD BE
<br /> RETAINED BY T"Ill`s TANK.OWNER,
<br /> A't.,C F CAIN��aC)R 'lA
<br /> '1' I? I sib , JRCLS CON'T'ROL BOARD
<br /> ,C/,o A ..I.. .S.
<br /> DATA I'ROC ESS G CENTER
<br /> R
<br /> � k P.0 I3OX 527
<br /> PARAMOUNT,NT,CA 90723
<br /> 3'93
<br /> FOR012ORI
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