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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 271 I OF TITLE 23,CHAPTER 16,CALIFORNIA COBE OF REGULATIONS AND SECTIONS 25286,25297,AND 25284 OF CHAPTER
<br /> 6;7,DIVISION 20.CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LIST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANCES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2, StJ13N1 T ONLY ONE(1)FOR I'A"for a Facility/Site,regardless of the number of tanks located at the si€e,
<br /> 3_ This forrn should be completed by eid=er the PER?\4iT APPEICANT or tire LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4, Please type or print cleanly all requested inforinaation, _. _
<br /> 5, Use a hard point wtdting s`nstrument,you are making 3 copies, -
<br /> 6. Tank owner must submit Sa facility plot pian to the hand agency=-as part of the application showing the location of the USTs with respect-ire
<br /> buildings and landmarks(Section 2711 (a)(8),CCR].
<br /> 7. Tank owner tasust submit rlcrcurnertalti€Yn show€ng ciarnpliatnce with state financial responsibility requirements to the local agency as part of the
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<br /> application for petroleum USTs[Seel ion 2711 (a)(1I),CCR]. �
<br /> TOP OF FORM:"MARK ONLY ONE I"£"3:M"
<br /> Mark an(X)in the box next to the iteral that best describes the reason the form is being completed.
<br /> L FACILITY/SITE INFORMATION c4 ADDRESS(It UST RE CONE'Ll"' ED)
<br /> I, Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location'Including city,sttate and zip code.
<br /> P,O,BOX NUMBERS ARE.NOT
<br /> ACCEPTABLE.
<br /> Include nearest crossstrect are;lima e of the operator.
<br /> 2. Phone number must have an area codeIf therfight pur bur i= s a _etirnc,write"SAME"in proper location.
<br /> 3. Check tate appropriate box for`T Y 'e.,Ol"LIL S IN"ESS.`S NIEa SHIII(tx.CORPORATION,INDIVIDUAL.etc,),
<br /> 4. Check the appropriate box for TYPE f OF BUSINESS.
<br /> 5_ If Facility/She is In ated within an I dian res, x anion or other l..ban t."zcg lands,check the box remarked"YES",
<br /> 6. Indicate the NUMBER of TAMC at this M.
<br /> 7. Record the E.F.A.ID#or write°N'O.NE"it th.space provided-
<br /> 11, PROPERTY OWNER INFORMATION&ADDRESS(N .,'ST Pf;COMPLET- D)
<br /> Complete all dents in this section, nnhaees all nears are he sa:m as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to chuck PROPERTY O 9EIlSHIP T YF' ,box.
<br /> LII.TAI*II4 OWNER INFORMATION A,a`sDDRE.S (MUST BE CONAPI.ETED)
<br /> Complete all norms in this section,tin,less a'I n.,rms ar e the saes.:s s SECTION 1,If the same,write"SAME AS SITE"`across this section. Be snare
<br /> to check TANK OWNERS TYPE box,
<br /> IV.BOARD OF EQUALIZATION UST STORAa;I,F-141,ACCOUNT NUMBER(MU'ST"BE COMPLETED,SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAI17Y CODE.)
<br /> Enter your Board of liqualiraliion(BOE)UST storage foe account number which is required before your permit application can be processed.
<br /> Registration won the BOTS will ensure that you will receive a quarterly storage fee return in reporting the per gallon fee sine on the number of
<br /> galleons placed in your US Is. The POE will code persca,s exempt from pryrn R the storage fee so retums will not be sent. If you do not have an
<br /> account number,vit?h the BOE or of you have any questions repryding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BC E at the following address 13c an,r`Equ aa",ateon,Fuel Taxes Di i:bi n,x.O.Box 942879,5acturnento,CA 94279-0001,
<br /> V. PETROLEUM UST FINANCIAL.RESPONSIBILITY(MUST BE CE)mPLE`T"ED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(i 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the methods)used by,the owner anchor operator,in meeting the Federal and State financial re onsibi[ity requirements.USTs owned by
<br /> any Federal or State agency as well as non-petro€turn USTS are exempt frotu this requirernem
<br /> V1,LE'GAL.NOTIFICATION AND B1. ,v A DDRES',S
<br /> Check ONE BOX far the address di tt will he used for 1"1E)`UI LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER ER 16,CALIFORNIA CODE OF REG=ULATIONS.]
<br /> INSTRUCTION FLIT THE LOCA ACEE vtCI:ES
<br /> The county and jurisdiction num arta P calm r-n-a ed,and can be obtained by calling the State Board(916)227-43€I3. The facility number may
<br /> be assigned by the local agency;however, inwt be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to nssigm the facilo s a anber pl s leave at bark.
<br /> IT IS THE RESPONSIBILITY t._ ,k . I_C`_.. L �k s4 THIAs Nr711 E ars Text, FACILITY TO VER.Ia Y tri ACCURACY OF THE
<br /> INFORMATION,ION, TEAS APPLnle A a RIN CANNOT BE PROCESSED IF THE ROE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY' INFORMATION BOX, THE LOCAL
<br /> AGENCY SHOULD RETAIN TENT ORIGINAL ANN YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
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