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INSTRUCTIONS FOR COMPLETING FOPM "All <br />GENFRAL INSTRUCTIONS: <br />SECTION 2711 OF TITLE 23, CHAPTER 16, CALIFORNIA CODE f; t-RE(aiJLATIONS AND SECTIONS 25286, 25287, AND 25239 OF CIIAPTER <br />6,7,,izl ISLQN.20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LIST OPERATING PERMIT, <br />I. One FORM "A" shall be completed for all NEW PERMIT CHANGES or any FACILITYISITE INFORMATION CHANGES. <br />2, SUBMIT ONLY ONE (1) 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 LOCAL AGENCY UNDERGROUND TANK INSPECTOR, <br />4. Please type or -prim clearly all requested information. <br />5, Use a hard point writing instrument, you are snaking 3 copies. <br />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• <br />buildings and landmarks (Section 2711 (a)(8), CCR). <br />7. 'Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part 9f the <br />application for petroleum USTs [Section 2711'(a)(11), CCR]. <br />TOP OF FORM: "MARK ONLY ONE ITEM" <br />Mark an (Y) in the box next to the item that best describes the reason the form is being completed. <br />.FACILITY/SITEFACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) <br />I. 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 />P.O. BOX NUMBERS ARE NOT ACCEPTABLE. <br />Include nearest cross street and name of the operator. <br />2,.' Phone number -toast have an area code. If the night, number is:the same, write "SAME" in proper loFation. . <br />3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex, CORPORATION, INDIVIDUAL, etc.), <br />4, Check the appropriate box for TYPE OF BUSINESS. <br />. if I'acility7Sits is located within an Indian reservation or oth& Indian trust lands,'check the box marked'"YES" <br />6. Indicate the NUMBER of TANKS at this SITE. <br />-7_ Record the E:P:A. ID # or write "NONE" in the space provided, <br />11. PROPERTY OWNER INT-ORMATION & ADDRESS (MUST BE COMPLETED) <br />Complete all items in this section, unless all iterns are the same as SECTION 1; If (be same, -write "SAMP AS SITE" across this s'cctiom Be sure <br />to check PROPERTY OWNERSHIP TYPE box. <br />III. TANK OWNER INFORMATION & ADDRESS (MUSTER COMPLETED) _ <br />_ to nplete all bems'in this section. unless all items are the same as SECTION 1; If the same, write "SAME AS SITE," across this section, Be sure <br />to check TANK OWNERS TYPE. box. <br />IV, HOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6,75, <br />DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODF,) . <br />Enter your Board of Esluafizatitits (BOE) LIST storage fee account number which is required before your pertxtit apI lidatien rail be processed, <br />Registration with the BOE will ensure that you will recei <br />