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�. ---e .�. .ye� - ms *-- 't INSTRU&ONS FOR COMPLETING F-em "A" GENERAL INSTRUCTIONS: SECT 10N 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 PERMIT CHANGES or any FA+CBZrYJSUE 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,ageney as pant of the application showing the location of the UST&with respect to buildings and landmarks[Section 2711 (4)(8),CCR]. 7. Tank owner mini 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),CCR]. TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the form is being 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 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 B USINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the bolt marked"YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A.ID#or write"NONEE"in die space provided. IL PROPERTY OWNER LNFOR-MATION&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 SI'Z'E"across this section. Be sure to check PROPERTY OWNERSHIP TYPE lox. III-TANK OWNER 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 chcck TANK O1VNE'RS TYPE box. IV.BOARD OF EQUALIZATION UST STORAGE FE ACCOUNT NUMBER(MUST.BE CO_lIPLETED.SEE ARTICLE 5,CHAPTER 6.75, DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE'.) Enter your Board of Equalization MOM)USTstorage fee account number which is required before your permit application can be processed. ReL istration with the BOE will ensure that you will receive a quarterly storage fee rttum,in reporting (Oniil.)k)per gallon fee due on the number of gallons placed in your USTs. 'the BOF"will code persons exempt from'paying the storage ft!ti so returns will not be sent. If You do not have an account number with the BOE or if you have any questions rcgardntg the fee or exemptions,please call the ItOl at 916-3229669 or write to the BOE at the following address Board of Equalization,Fucl Taxes Division,P.O.Box 942879,Sacramento,CA 9.4279-0001. V. PE (.\1UST BE COMPLETED FOR PE-1110111M USTs ONLY;SEE-SEC-1 IONS 2711 (a)(S) OF 711I_E 23,CHAPTER 16,CALII'OICNIA CODE OF RI:GULATIONS.) Identify the niethod(s)used by the owner andior operator,in meeting the Federal and State financial responsibility requirements. USTs owacd by any Federal or State agency as well as non-petroleum USTs are exempt from this-requirement. VI.LEGAL NO'IIFICATION AND BILLING ADDRESS Check ONII3OX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AUTHORIZED REPRESENTATIVE MI SI'SIGN ANDDATE TIIE FORM AS LI DILA-I'I:D. [SLE SI;C"fdONS 2711 (a)(13)OF TITLE 23 CIIAPI'L'R 16,CALIFORNIA CODE Or REGULATIONS.] s. INSTRUCTION FOR THE LOCAL AGENCIES w. The county an jurisdiction numbers are predetennined and can be obtained by calling lh4'StateBoard(916)227-4303. The facility number may be assigned by the local agency;however,this nurnber must be.numerical and cannot cotitain•anyalphat ctical characters. If the local agency prefers the State Board to assign the fatuity number,please leave it blank. IT 19 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS TH19l FACitXrY1O VERIFY THE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE I..00AL 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 F('s1I,LxOfVING ADDRESS. THF.LOCAL AGENCY SHOULD RETAINTHE ORIGINALS AND FORWARD THE YELLOW COPIES TO TIIB FOLWW.ING.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 3193 FOP41MRI