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INSTRPTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS;
<br /> I ION 2711 OF T I I LE.23,CFEAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> IVISION 20,CALIFOI2\1A HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. e,FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFOR.Iv1ATION CHANGES.
<br /> .jumvll r O1NF..Y ONE(1)FORM"A"for Facility/Site,regardless of the number of tanks located at the site.
<br /> his form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDEMOROUND TANK INSPECTOR,
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit,a facility plot plait 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 of the
<br /> application for petroleum UST's[Section 2711(a)(]1),CCR].
<br /> TOP OF FORINT:"MARK ONLY ONE II`EM" I
<br /> Mark an(X)in the box next to the item that best describes the reason the form is beh'g completed.
<br /> L FACILITY/SI'Z'E L\FORMA'ITON&ADDRFSS(MUST BE COMPLETED)
<br /> 1. 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 must have art area code. If the night number is the same,write"SAME"in proper location.
<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 /> 5. If Facility/Site is located within an Indian reservation or other 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 /> H. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLE-TED) t.
<br /> 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. lie sure
<br /> to check PROPERTY OWNERSI lip TYPE'box.
<br /> III.TANK OWNER I FORMA"l ION&ADDRESS QMUSI"I3E COMPLETED)
<br /> Complete all items in this section,unless all itents are the same as SECTION 1;If the same,write"SAME AS SI T Fs"across this section. Be,sure
<br /> to check-TANK OWNERS TY1111 box.
<br /> IV.BOARD OF E.QUAI.JZATTON USI STORAGE FEE ACCOUNTNUMBER(MUST BE COMPLETED.SEEARTICLE S,CIIAPH1',R 6.75,
<br /> DIVISION 20,CALIFORNIA 111 AL;I11 AND SAFETY CODE.)
<br /> Enter your Board of I;it""tl r.s;.ion(1100)t ST storage fee account number which is required before your pennit application can use proccKsed.
<br /> Registration with the BOP will etr urc that you will.receive a quarterly storage fee return in reporting the S0.0)6(6ntilk)pe:r gallon fee due on the
<br /> number of T allot.,piae;;;d in your S'f's. 'Itic!130E will code persons exempt from paying the storage fee so returns w-11 not be sent_ if you do nm
<br /> have:an acexautt nurrdxr with the BOF or if you have any questions regarding the fee or exemptions,please call the 1301:1'al.c}16-3229669 or wwrite
<br /> to the 1301:at the hollow+"ing address Board of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94270-0001.
<br /> V. PE 1ROId'UM UST FINANCIAL,RI-:SPONSIBILITY(MUST BE COMPLETED FOR PEs1ROLEuN1 USTs O`I..Y,SI?.1:SEC TIONS 2711 szd)( )
<br /> OF`1ITLE 23,CHAPTER 16,CALIFORNIA C'ODI.'s OFA P EGULA`1TIONS.)
<br /> Identify th rntahcxl(s,}used by tl_ ,.�-r:�r a;4:, t�ttg the hederal and State financial espclnsi`,u 4',';f,_• sly
<br /> any Fcdei"al or State agency as v-l .�nc>rt p -e3lcn rt US"I s ar.;exempt front this tuluiremcnt.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check-ON11 1.3OX for the address that evjll be used for BOTH LEGAL AND BILLING NO'l II[CA"I It:ONS.
<br /> TANK OWNER OR AUTHORIC..I l)REI'Rf.SENTATIVE MUST SIGN AND DATE:TIIE FOR.Nil AS INDICATED,El.?. (�t:t.Si.E. IO S 2711
<br /> (a)(13)OF-1 ITI-Ii.23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.[
<br /> LNSTRUCITON FOR THE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calting the;State Hoard(916)227-4303. The facdoy number may Nc
<br /> assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. IP the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS THE.' R1:SPONSIBILIT'Y OF T HL LOCAL AGENCY THAT INSPECT'S THE FACILITY TO VERIFY THE ACCURACY OF'[HE
<br /> INFORMATION. TIIIS APPLICA'T'ION CANNOT BE PROCESSED IF THE BOF,ACCOUNT NUMBER IS NOT FILLED I.N. TILE I.,OCAL
<br /> AGENCY IS RESPONSIBLE FOR THE C:OMPI..ETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM'11"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RET'AINE 1)13Y THE TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P,S.
<br /> DATA PROCESSLNG CENTER.
<br /> P.O BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3x93 FORp120M
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