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INSTRUCTIONS FOR COMPLETING FORIM "All
<br /> GENERAL AL INS RUCTIONS;
<br /> ST-CITON 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA(,,'ODE OF REGULATIONS AND SECTIONS 25286,25297,AND 25281 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> I:One FORM "A"shall he completedfor all NEW PERMIT CHANGES or anyFACILITY/SITE INFORMATION CHANGES.
<br /> 2, SUBMIT ONLY ONE(I)FORIM"A"for a Facil.ity/Site,r,gardiess of the number of tanks located at the site.
<br /> 3. This farm should be completer{by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard paint u>ritietg insteurnern,you are making 3 copies,
<br /> 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the LISTS 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 USTs[Section 2711(a)(11),C:CRI.
<br /> TOP OF FORM;"MARK ONLY ONE ITEM"
<br /> Mark an(5C)in the box next to the item that best describes the reason tate form is being completed.
<br /> T. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. Record name and address(physical location)of the underground tank(s),
<br /> DOTE: 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 an area code, If the tight 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 /> S. If Facility/Site is located within an Indian resma€ion 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"its the,space provided,
<br /> II: PROPERTY OWNER INFORMATION&ADDRESS(MUST"BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the saris:,write"SAME AS SITE"across this section, Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,sinless all items are the same as SECTION 1;If the sa=me,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box,
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20;CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration.with the BOE will ensure that you will receive a quarterly storage fire return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTta:'The BOB will code persons exempt ftorn paying the storage Pee so returns will not be sent. If you do not have an
<br /> account number with the BOB or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOB at the following,address Board of Equalization,Fuel Taxes Division,P,O.Box 942879,Sacramento,CA 94279-0001.
<br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM LS`I`s ONLY.SEE SECTIONS 2711 (a)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.USTs owner[by
<br /> any Federal or State agency as well as non-petroicuru USTs are exempt from this requirement. '
<br /> VI,LEGAL,NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address haat will be used for BOTH,LEGAL AND BILLING NOTIFICATION'S
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA.CODE OF REGULATIONS,]
<br /> 6:
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The courity and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4301 The facility number may
<br /> be assigned by the local agency;however,this nunaber must be numerical and cannot contain any ilphabetical characters. If the local agency
<br /> prefers the State Hoard to assign the facility number,please leave it'blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> - IANFORMATION.,.THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORMATION BOA. ,THE LOCAL,
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COrIES,._THE.PINK COPY SHOULD BE RETAINED BY THE'Tr'i;N,IC.
<br /> OWNER,
<br /> 619 ..
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