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INSTRUCTIONSl "A"
<br /> GENERAL INS rR ICTI NS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA NIA OD OF REGULATIONS AND SECTIONS?:286,252&'°x,AND 25259 OF CHAPTER_
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST CIPERATINQ,PERMIT.
<br /> 1, One.FOR „A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY EINE(I)FORM"A"for:a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This forty shouid be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANI:INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Lase a hard Point writing instruntent,you arc Snaking 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 USTs with respect to
<br /> buildings and landmarks(Section 2711 (a)(S),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 petroleurn USTs(Section 2711(a)(I I),CCR).
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an OQ in the box next to the item that best describes the reason the form is being completed.
<br /> L FACILITY/SITE INFORMATION&ADDRESS(MUST BE:COMPLETED)
<br /> I. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have at valid physical location including city,state,and zip code,
<br /> P.0,BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest crass street and mance of the operator,
<br /> 2. Phone number must have an arca code, If the night number is the same,write"SA E"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 Indiana reservation or other Indian trust lands,check tie bora marked"SES".
<br /> 6, Indicate the NUMBER of TANKS at this SITE,
<br /> 7. Record the E.P_A.IU#or write"NONE"in tote space provided. _.
<br /> 11, PROPERTY OWNER INFORMATION&c.ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items acre the same as SECTION l.,If the same,write"SAME AS SITE,"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the sante as SECTION I;If the same,write"SAME AS SITE".across this.section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION LIST STORAGE FTSE ACCOUNT NUMBER(MUST"BE COMPLETED.SEE ARTICLE 5,CHAPTER 6,75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalisation(BOE)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure haat you will receive a quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs, The BOE will elide pers6ns exempt from paying the storage fee so returns will not be sent:If you(Ila not have aro
<br /> accotin€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 sof Equalization,Fuel Taxes Division,P,O7 Box 942579,Sacramento,CA 94279-0001, .
<br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST"BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711(a)(I1)
<br /> OFTITLE'23,CHAPTER 1.6,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 owned by
<br /> ate
<br /> any Federal or Stagcncy as well as non-petroleum USTs are exempt froin this requirement.
<br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL.AND BILLIN{.',,NOTIFICAT!ONS.
<br /> TANK.OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHARTER 16.CALIFORNIA CODE OF REGULATIONS.)
<br /> INSTRUCTION FOR"TETE:LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-43011 ,Tile facility number may
<br /> be assigned by the htc agcncy;however,this another 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. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THEOCAL,
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE -LOCAL AGENCY USE ONLY' INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE,ORIGINAL,AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
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