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GENERAL INSTRUCTIONS:
<br />SECT -TON 2711 OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 201, CALIFORNIA HEALTH AND SAFETY CODE REqUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />I. One FORM "A" small be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORiNIATION CHANGES.
<br />2. SUBMIT ONLY ONE (1) FORM ";A" for a FacilhylSite, regardless of the number of tanks located at the site.
<br />3. This fort should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK INSPECTOR.
<br />4. Please type or print clearly all requested information.
<br />5. Use;a harticrirst writ€S�g irsil a raflt, 3°ou �tre'rataaag 3 ccsis.,.,:
<br />6. Tank owner must submit a facility plot plan to'the local agency as part of the applicatiosa �lsovvit g the [o orlon of the I � t � w tYs respect tel"
<br />buildings and landmarks [Section 2711 (a)(8), CCR]. m
<br />7. Tank owner mast submit documentation.sho0ing comp `. ce with state financial responsibility requifentents"to the,lescal agency. part ofihe` », .. •.
<br />application for petroleum USTs [Section 2711 (a)(I 1), CCR].
<br />TOP Old FORM: "SIA k ON
<br />i�Y ONE iiE'vi..
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />I. FACILITY/SITE INFORMATION & ADDRESS (MUST BECOMPLETED)
<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. BOK 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 might number is the same, write 'SAME" in proper location.
<br />3. Check the appro !ate box for TYPE OF,BUSINESS OWNERSHIP (ex. QORPORATION, INDIVIDUAL, etc.).
<br />c�k the
<br />riate
<br />o,, a 5 f1Facility/Site isploca d wt hin an Indian reservation or other Indian trust lands, check the boxf marked"YES".
<br />" f"YES°'. �' h
<br />y
<br />6. ivdieate the NUMBER €af,TANKS at,this�SfTEE
<br />7. Reccsrd the E.P.A. ID ff or write "NOIR ` in the space p rsvided.
<br />ll. 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 same, write "SANEAS SITE" across this sections. Be die
<br />to check PROPERTY OWNERSHIP TYPE box.
<br />III. TANK OWNER INFORMATION & ADDRESS (DUST BE COMPLETED)
<br />Complete all iterns in this section, unless all items are the same as SECTION 1; If the sarrse, sprite "SAME AS SITE" across this.sec€ioft: Be aure'\ b
<br />to check TANK OWNERS TYPE box.
<br />IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT" NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 05,
<br />DIVISION 20, CALIFORNIA HEALTH AND SAFETY COLE.)
<br />Easter your Hoard of Equalization (BOE) UST storage fee account number which is required before your permit application can be processe€I.
<br />Registration in the
<br />BOE wjll ensure that
<br />ill c ill recess e aquarterly storage fee return in reporting the per gallon fee due,,on tliq number o�
<br />Registration 1 [ �
<br />p y o persons
<br />mpt from paying the storage fee so retuni's will not be sent. `'If`you dl's not,bavean
<br />account number with the BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-322-9669 or write to the
<br />BOE at the following address Board of Equalization, Fuel Taxes Division, P.O. Box 942579, Sacramento, CA 279-(1601,..
<br />V, RETRCiLEU"UST FINANCIAL, RESPONSIBILITY (MUST 1$E COMPLETED FOR PETROLEUM LSTs ONLY, SEE SECTIONS 2711 (a$(I1)
<br />t51"'ilTLE ?3 CEIAPT`E -r6, CALIFOR'NlA Ct3L)6 - REGUi:f TIONS.)
<br />Identify the method(s) used by the owner and/or operator, in meeting the Federal and State financial responsibility requirements. LISTS owned by
<br />any Federal or State agency as well as non -petroleum UST's are exempt fro€n this requirement.
<br />VI, LEGAL NOTIFICATION AND BILLINGS ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND BATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br />(a)(13) OF TITLE: 23 CHAPTER 16, CALIFORNIA CODE OF REGULATIONS.)
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303, The facility number may
<br />be assigned by the local agency; however, this number must be numerical and cannot contain any alphabetical characters— If the local agency
<br />prefers the State Board 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 />INFORMATION, TTiIS APPLICATION CANNOT BE PROCESSED IF THE 1303E 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,$HOULD RETAIN THE ORIGINAL, AND YELLOW COPIES. T.,Ht PINK COPY,SHOULD BE RETAINED BY THE TANK
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