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<br />INSTRUCTIONS FOR communNG FORM "A"
<br />GENERAL INSTRUCTIONS -
<br />FORM "A" shall be completed for all NEW PERMTIN, PERMIT CIIANGEN or any FACILirry/sirru,
<br />.AAIION CHANGES.
<br />2, SUBMfl'ONLY ONE (1) FORM *A* for a Facility/Sitc, regardless of the number of tanks located at the hilc-
<br />,'°, Od be completed by either the PERMIT APPUCANT or the LOCAL AGENCY UNDFRGROUND
<br />TANK INSPECTOR.
<br />4. Please type or print clearly all requested information.
<br />5. Use a hard point writing instrument, you are making 3 copies.
<br />TOP OF FORM- "MAIM ONLY ONE ITEM"
<br />Mark an (X.) in the box next to theitemthat best describes the reason the form is being completed.
<br />1. FAC1111 Y/SffF I]NPORMK1ION & ADDR14-SS (MUST BE. COMPI-14:113D)
<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 ARI? NOT AC(37rABLI3.
<br />Include nearest cross street and name of the operator.
<br />2. Phone number must have an 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, INDIVIDUAI, 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. PROPEWI'Y OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete all items in this section, unless all items are the same as SECI I ION 1; if the same, write "SAME; AS S1111," acn)ss
<br />this section. Be sure 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 same as SECTION 1; If the same, write "SAME" AS sirm., ;1cr01;s
<br />this section. Be sure to check TANK OWW--RSII1P TYPE box.
<br />IV. BOARD OF EQUALIZATION UST ' 1UyJRAGE FEE ACCOUNT NUMBER (MUST BE COMPLE310)
<br />Enter your Board of Equalization (BOB) UST storage fee account number which is required before your permit application
<br />can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting ilic
<br />$0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from
<br />paying the storage fee so returns will not be sent. If you do not have an account number with the 130E or if you have any
<br />questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address:
<br />Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001,
<br />V. PETROLEUM UST 14NANCIAL RESPONSIBIL117117Y (MUST BE COMPLETED)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br />VL LEGAL NOTIIICATION AND BILLING ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH IJXyAL AND BILIING NO11FICATTONS.
<br />APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdiction numbers are predetermined and can be obtained by calling0 the State Board (91.6)739-2421. The
<br />facility number may be assigned by the local agency-, however, this number must be numerical and cannot contain any
<br />alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br />IT IS 'IIW- RESPONSIBUXI'Y OF THE LOCAL AGENCY THAT INSPECTS 17HE FACILITY To VI-MFY THE
<br />ACCURACY OF THE INFORMATION. THUS APPLICATION CANNOT BE PROCE�SSED IF THE BOE ACCOUNF
<br />NUMBER IS NOT PILLED IN. THE LOCAL AGENCY IS RESPONSHILE FOR IIIE COMPLETION OF THE
<br />*LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A' AND
<br />ASSOCIATED FORM '13'(s) TO 114E FOLLOWING ADDRESS.
<br />SFATE, OF CALIFORNIA
<br />STATE WAI'ER RESOURCE -S CONTROL BOARD
<br />C/O S.W.F-R-P-S.
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 9o723
<br />INSTRUCTIONS FOR communNG FORM "A"
<br />GENERAL INSTRUCTIONS -
<br />FORM "A" shall be completed for all NEW PERMTIN, PERMIT CIIANGEN or any FACILirry/sirru,
<br />.AAIION CHANGES.
<br />2, SUBMfl'ONLY ONE (1) FORM *A* for a Facility/Sitc, regardless of the number of tanks located at the hilc-
<br />,'°, Od be completed by either the PERMIT APPUCANT or the LOCAL AGENCY UNDFRGROUND
<br />TANK INSPECTOR.
<br />4. Please type or print clearly all requested information.
<br />5. Use a hard point writing instrument, you are making 3 copies.
<br />TOP OF FORM- "MAIM ONLY ONE ITEM"
<br />Mark an (X.) in the box next to theitemthat best describes the reason the form is being completed.
<br />1. FAC1111 Y/SffF I]NPORMK1ION & ADDR14-SS (MUST BE. COMPI-14:113D)
<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 ARI? NOT AC(37rABLI3.
<br />Include nearest cross street and name of the operator.
<br />2. Phone number must have an 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, INDIVIDUAI, 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. PROPEWI'Y OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete all items in this section, unless all items are the same as SECI I ION 1; if the same, write "SAME; AS S1111," acn)ss
<br />this section. Be sure 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 same as SECTION 1; If the same, write "SAME" AS sirm., ;1cr01;s
<br />this section. Be sure to check TANK OWW--RSII1P TYPE box.
<br />IV. BOARD OF EQUALIZATION UST ' 1UyJRAGE FEE ACCOUNT NUMBER (MUST BE COMPLE310)
<br />Enter your Board of Equalization (BOB) UST storage fee account number which is required before your permit application
<br />can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting ilic
<br />$0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from
<br />paying the storage fee so returns will not be sent. If you do not have an account number with the 130E or if you have any
<br />questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address:
<br />Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001,
<br />V. PETROLEUM UST 14NANCIAL RESPONSIBIL117117Y (MUST BE COMPLETED)
<br />Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility
<br />requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br />VL LEGAL NOTIIICATION AND BILLING ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH IJXyAL AND BILIING NO11FICATTONS.
<br />APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdiction numbers are predetermined and can be obtained by calling0 the State Board (91.6)739-2421. The
<br />facility number may be assigned by the local agency-, however, this number must be numerical and cannot contain any
<br />alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank.
<br />IT IS 'IIW- RESPONSIBUXI'Y OF THE LOCAL AGENCY THAT INSPECTS 17HE FACILITY To VI-MFY THE
<br />ACCURACY OF THE INFORMATION. THUS APPLICATION CANNOT BE PROCE�SSED IF THE BOE ACCOUNF
<br />NUMBER IS NOT PILLED IN. THE LOCAL AGENCY IS RESPONSHILE FOR IIIE COMPLETION OF THE
<br />*LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A' AND
<br />ASSOCIATED FORM '13'(s) TO 114E FOLLOWING ADDRESS.
<br />SFATE, OF CALIFORNIA
<br />STATE WAI'ER RESOURCE -S CONTROL BOARD
<br />C/O S.W.F-R-P-S.
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 9o723
<br />
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